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Full text of "U.S. Navy Medicine Vol. 69, No. 7 July 1978"




VADM Wiilaid P. Arentzen, MC, USN 
Surgeon General of the Navy 



RADM R.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 

Director of Public Affairs 

ENS Richard A. Schmidt, USNR 

Managing Editor 

Ellen Casselberry 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 

Nancv R. Keesee 






Contributing Editors 

Contributing Editor-in-Chief: CDR C.T. 
Cloutier (MC); Aerospace Medicine: 
CAPT M.G. Webb (MC); Dental Corps: 
CAPT R.D. Ulrey (DC); Education: 
CAPT S.J. Kreider (MC); Fleet Sup- 
port: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.A. 
Olszak; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. 
Hauler (MC); Medical Service Corps: 
CAPT P.D. Nelson (MSC); Naval Re- 
scue: CAPT J.N. Rizzi (MC. USN); 
Nephrology: CDR J.D. Wallin (MC); 
Nurse Corps: CAPT P.J. Elsass (NC); 
Occupational Medicine: CDR J.J. Bel- 
lanca (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT S.J. Kreider (MC); Research: 
CAPT J.P. Bloom (MC); Submarine 
Medicine: CAPT J.C. Rivera (MC) 



POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer: one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor. U.S. Navy Medicine. Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010). 
Washington, D.C. 20372. Telephone: (Area Code 2021 254- 
4253. 254-4316, 244-4214: Autovon 294-4253. 294-4316. 294- 
4214. Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Naw Publications and Printing 
Regulations (NAVEXOS P-.lj). 



U.S.MYY 




Vol. 69, No. 7 
July 1978 



1 From the Surgeon General 



2 Department Rounds 

Topsy-Turvy World of R&D . . . Personnel Changes Afoot 

4 Instructions and Directives 

6 Scholars' Scuttlebutt 

Clerkships at Navy Medical Facilities 

8 Notes and Announcements 

10 Features 

Medical Practice at Sea 
CDR L.C. Ellwood, MC, USN 
HMCR.B. Littlejohn, USN 

16 Career Pathways for Nurse Corps Officers 
CDR A. Langley, NC, USN 

IS NAVMED Newsmakers 

19 Professional 

Child Abuse as a Major Cause of Retardation 
ENS S.B. Hester, USNR 

22 The Role of Preventive Dentistry in the Navy 
CAPTM.R. Wirthlin, Jr., DC. USN 

26 Outpatient Medical Records Audit: A Dialogue 

29 BUMED Sitrep 



COVER: A CH-46, on a medevac mission, comes aboard the USS Inchon 
(LPH-12). For a closeup look at shipboard medical practice, see page 10, 



NAVMED P-50SS 



From the Surqeon General 



Turning Barriers into Bridges 



Compare today's health-care en- 
vironment—both within the Navy 
and outside it— with that of just a 
few years ago. Consider the quan- 
tum changes that have occurred in 
population dynamics, communica- 
tion, data processing, financial 
management, and energy. 

Health care today is a highly com- 
plex enterprise, impacted upon by 
these and many other realities. The 
time is long past when one individ- 
ual, in one profession, can deal with 
it all. 

Nevertheless, no one element can 
be dealt with in isolation from 
others. 

We are professionals, all of us, in 
the Medical Department. And we 
are dependent, each of us upon the 
other, for accomplishment of the 
department's mission. 

Fostering a spirit of unity is one 
of my most important goals. But 
this spirit will elude us unless we 
step back, from time to time, and 
reflect on each other's contribu- 
tions. 

This month I would like to talk to 
you about the contributions and 
potential of the Medical Service 
Corps. Explosive technological 
change and advances in manage- 
ment theory led to the establish- 
ment of this corps. Present and 
future developments will inevitably 
require expanded responsibilities 
for its members. 




At no time have the opportunities 
in this area been brighter. Health 
care is a growth industry, consum- 
ing an ever-increasing share of the 
gross national product. And simple 
prudence, as well as heightened 
visibility, demands accountability. 

Health-care administrators and 
financial planners are in short sup- 
ply: there is more than enough work 
to go around. We must strengthen 
our direct- accession programs to 
give us a broad mix of academic 
backgrounds. At the same time, we 
must continue to select highly moti- 
vated and talented members of the 



Hospital Corps for in-service officer 
procurement, taking advantage of 
the experience base they bring to 
their assignments. 

Modern medicine, with its con- 
stantly growing sophistication, has 
an insatiable appetite for allied- 
science expertise — not only in the 
usual laboratory roles, but, more 
and more, in clinical responsibili- 
ties. I see no evidence of a decrease 
in this trend: we must keep up with 
the state of the art. 

I expect innovative thinking; I re- 
quire inventive management. As 
health care comes under ever- 
greater government control and re- 
view, the opportunity to work — and 
exert an influence — on this frontier 
should be an exciting challenge to 
imaginative, creative professional 
growth. 

We are one Medical Department, 
not a series of autonomous units. If 
before there were barriers, I want 
those barriers to become bridges — 
to each other and to our patients. 

Opportunity is constrained only 
by the limits of your imagination. 



A 



/: 



1 



Uj+^J^ 



W.P. ARENTZEN Qj 
Vice Admiral, Medical Corps 
United States Navy 



Volume 69, July 1978 



Department Rounds 



Topsy-Turvy World of R&D 



Anyone who's ever been upside 
down in an airplane knows it's a 
sine qua non to be strapped in tight- 
ly. But anyone who's had to be on 
the lookout for enemy aircraft or 
missiles knows that, in such situa- 
tions, there's an equally important 
need for some freedom of move- 
ment. 

Pilots and crewmen have com- 
plained about these conflicting ne- 
cessities for years. Several different 
types of restraining device have 
been developed over time, and each 
has been through many modifica- 



tions. But the capabilities of these 
devices simply have not kept up 
with aircraft capabilities. 

Now the Navy has decided that 
the standard torso harness restraint 
system will no longer fill the bill. As 
a result, Medical Department per- 
sonnel at the Naval Air Test Center, 
Patuxent River, Md., are participat- 
ing in a research effort that could 
lead to an entirely new system. 

"Our job at this point is simply to 
identify the problem," says LT Bob 
Bason (MSC), an aviation physiolo- 
gist in the Systems Engineering 



Test Directorate at NATC. While 
the shortcomings of the system 
were a matter for conjecture before, 
he adds, "We are gathering evi- 
dence now." 

In so doing, LT Bason and a team 
of five volunteers are subjecting 
themselves to some very disagree- 
able duty. 

After donning the MA-2 torso 
harness used in all Navy aircraft 
with ejection seats, the volunteer is 
strapped into a homemade device 
that has been fittingly nicknamed 
"the rack." The device turns the 
wearer upside down and holds him 
there for as long as he can stand it, 
while precise measurements of his 
body movements are made. 




HM1 Jim Folz braves 'the rack' while HM2 Jon Etneredge measures body shift. Photo by PHAN Brian Caughlan. 



U.S. Navy Medicine 



These upside-down moments are 
always uncomfortable — and often 
very painful. Only partly in jest, 
team members have blacked out the 
laboratory windows and made a 
practice of keeping the doors shut, 
lest their moans and groans disturb 
employees and prove unsettling to 
visitors. 

"We're very careful, and every 
test is well supervised," LT Bason 
emphasizes, "but the men are sub- 
jecting themselves to quite a bit of 
discomfort. Sometimes they dangle 
more than two and a half inches out 
of the seat, even though they have 
been strapped in very tightly. The 
straps and buckles often bite deeply 
into the flesh." 

And because the volunteers wear 
only swim trunks under the harness, 
so that measurement marks can be 
placed on their skin, they probably 
experience a great deal more dis- 
comfort from the straps and buckles 
than an aircraft crewman would. 

As to what has been learned so 
far, "We've only touched the tip of 
the iceberg," says LT Bason. But, 
he adds, the tests have already 
shown that the extent to which the 
MA-2 allows the inverted man to 
dangle from his seat "seriously de- 
grades the crewman's ability to per- 
form in the cockpit while experienc- 
ing G-forces." 

Moreover, he notes, "Our labora- 
tory tests are done at only 1G, while 
che pilot might be experiencing 6G 
or 7G in today's aircraft — and may- 
be 10G or 12G in aircraft of the fu- 
ture." 

The inertial reel, which is design- 
ed to retract the shoulder harness 
and pull the pilot back into his seat, 
has also proven inadequate, LT 
Bason explains. If the G-forces 
build up gradually — as happens in 
many instances — the inertial reel 
does not undergo the 2VtG sudden 
force necessary to activate it. The 
shoulder straps continue to pay out, 



with the result that the pilot may 
end up with his face buried in the 
instrument panel, and with little or 
no control over his movements. 

"Obviously, when the pilot or 
crewman is put into such an awk- 
ward position, it becomes very diffi- 
cult to operate the necessary con- 
trols," says LT Bason. "Sometimes 
he can't even reach the ejection seat 
handles," 

A study of medical officer reports 
on 920 ejections from aircraft has 
shown that 5% of the crewmen in- 
volved had a problem with the 
standard torso garment. In some of 
these cases, the men had made non- 
standard modifications in the har- 
ness or were otherwise not using it 
properly. But evidence from the 
early NATC testing shows that the 
integrated torso system does not 
meet the needs of those who use it, 



even when it is fitted and operated 
to perfection. 

"Clearly, the Navy needs a new 
restraint system for use with ejec- 
tion seats," says LT Bason, "but it 
might be a while before one is de- 
veloped. This is only the first stage 
in that possible development: the 
collection of data to properly iden- 
tify the problem." 

To supplement what the NATC 
volunteers are learning in their un- 
pleasant encounters with "the 
rack," the Navy is also gathering 
data through an aircrew personnel 
questionnaire. 

"Once we know exactly what is 
wrong with the present system," 
says LT Bason, "we can offer some 
design recommendations for a new 
system." 

He and his team hope to be able 
to do that by the end of this year. 



Personnel Changes Afoot 



Recently released orders for a 
number of Medical Department flag 
officers and flag selectees are bring- 
ing a spate of personnel changes 
over the summer months. 

At BUMED in September, RADM 
Henry A. Sparks (MC) will be Dep- 
uty Surgeon General and Assistant 
Chief for Headquarters Operation, 
replacing RADM Robert G. Wil- 
iiams, Jr. (MC), who is retiring. 
RADM Sparks's current post— BU- 
MED Assistant Chief for Opera- 
tional Medical Support — will be 
filled by RADM- selectee John R. 
I.ukas (MC), now Commanding 
Officer at NRMC Corpus Christi. 

RADM-selectee Melvin Museles 
(MC), formerly CO at NRMC Jack- 
sonville, is BUMED's new Inspector 
General, Medical, replacing RADM 
Roger F. Milnes (MC), who be- 



comes BUMED's Assistant Chief 
for Human Resources and Profes- 
sional Operations. That post is 
being vacated by RADM J. WiUiam 
Cox (MC), who will relieve RADM 
D. Earl Brown, Jr. (MC), as CO at 
NRMC San Diego. 

RADM Brown will replace RADM 
George E. Gorsuch (MC), currently 
Fleet Surgeon to CINCPAC. RADM 
Gorsuch will then take over as Com- 
manding Officer of NRMC Ports- 
mouth, Va., replacing RADM Wil- 
liam J. Jacoby, Jr. (MC), who re- 
tires this month. 

The Naval Regional Dental Cen- 
ter at Norfolk will also have a new 
Commanding Officer: RADM John 
B. Holmes (DC), currently serving 
as CO at NRDC San Francisco. He 
will replace RADM George A. Bes- 
bekos, who is retiring. 



Volume 69, July 1978 



Instructions & Directives 



Medical and dental items for standardization or testing 

Standardization of medical and dental items is based on one or more of the following criteria: 
(1) the item is necessary in the practice of military medicine or dentistry, (2) it is an insurance- 
type item, or (3) it is designed primarily for use in field combat units or other elements of the 
operating forces. Decisions on standardization are made on the basis of both professional and 
supply requirements. 

The Director, Equipment and Logistics Division, BUMED Code 43, is designated coordina- 
tor for item testing and evaluation in Navy medical and dental facilities. The Director, Medical 
Materiel Division, BUMED Code 42 (Commanding Officer, Naval Medical Materiel Support 
Command), is the Navy coordinator for standardization of medical and dental material. 

Testing. Normally, requests for testing and evaluation of medical and dental items are proc- 
essed prior to a recommendation for standardization. Requests should be forwarded via offi- 
cial channels to BUMED Code 43 (with a copy to BUMED Code 6 for dental items) and should 
include the following information: name and address of supplier; model number, catalog 
number, or other positive identification; requisition cost of the item; number of units required 
for testing; site(s) of test; duration of test; proposed testing protocol. 

Conditions for testing and evaluation: 

• The item to be tested will be provided at no charge to the Government. 

• The Government incurs no obligation or liability to the supplier as a result of acceptance for 
testing and evaluation. 

• The item will be returned to the supplier in "as is" condition upon completion of testing. If 
subsequent purchase is made, a new item must be furnished. 

• Evaluation reports will be the property of the U.S. Government, labeled for "Official Use 
Only," and shall not be released to industry without BUMED consent. 

Evaluation, When the test is complete, an evaluation containing all pertinent information on 
product performance and reliability will be forwarded to BUMED Code 43 (with a copy to 
BUMED Code 6 for dental items). Comments should include such considerations as ease of 
operation, technician acceptance, maintainability, quality of workmanship, and any hazards 
noted, together with any recommendations regarding standardization. 

Standardization. Recommendations for standardization of medical and dental material 
should be forwarded via official channels to the Commanding Officer, Naval Medical Materiel 
Support Command, 3500 S. Broad St., Philadelphia, Pa. 19145 (with a copy to BUMED Code 6 
for dental items), and should contain sufficient information and details to permit a thorough 
evaluation of the recommended item. 

Recommendations should include the following: descriptive data, including trade name, 
dosage form, strength, packaging, unit cost, manufacturer, model and catalog numbers; 
appropriate literature and manufacturer's brochures; justification for standardization.— BU- 
MED Instruction 6700. 33D of 9 Mar 1978. 

Recovery and use of precious metals 

DOD Directive 4160.22, Recovery and Utilization of Precious Metals (NOTAL), directs that all 
DOD components establish and monitor a program to reclaim precious metals to the maximum 
extent practicable for use as Government Furnished Material (GFM) to reduce costs of new 
procurement. 

NAVSUPINST 4570.22, Recovery and Utilization of Precious Metals (NOTAL), establishes 
the program within the Department of the Navy and directs that the Chief, BUMED, designate 
a coordinator to implement and monitor the DOD Precious Metals Recovery Program (PMRP) 

U.S. Navy Medicine 



in activities under the command of BUMED. 

Assignment of coordinator. The Naval Medical Materiel Support Command (NAVMED- 
MATSUPPCOM) is designated PMRP Coordinator for BUMED. 

Policy. All BUMED command activities generating precious metal bearing excess (items 
coded "M" in the Federal Supply Catalog), scrap material, or precious metal bearing residue 
(exposed and outdated X-ray film, photographic film, dental scrap, processing solutions, etc.) 
will participate in the PMRP. Navy funds will not be used for the procurement, maintenance, 
and repair of recovery equipment or shipment of material. 

Action. Activities shall identify potential sources of recoverable precious metals, ensuring 
training of personnel to recover the precious metals, ensuring availability and operation of 
recovery equipment, and establishing necessary internal control measures to fix an 
accountable audit trail. Assistance in indoctrination, facility survey, training, and other as- 
pects of precious metals recovery may be obtained directly from the Defense Property Dis- 
posal Precious Metals Recovery Office (DPDPMRO-E), NAD Earle, Colts Neck, N.J. 07832. 

To maintain a responsible program, the following procedures must be followed: 

• Operate and maintain precious metals recovery equipment under local cognizance, except 
where, by inter/intra service support agreement (ISSA), the local defense property disposal 
office (DPDO) provides recovery service. The use of ISSAs is encouraged. 

• Account for and turn in precious metal bearing items and recovered precious metals to the 
servicing DPDO and obtain a receipt at the time of turn-in. If directed to ship precious metal 
bearing materials or recovered precious metals to DPDPMRO-E, obtain a funding citation 
from the servicing DPDO. 

• Submit requirements, with justification, for recovery equipment, replacement, or major 
maintenance on existing equipment to DPDPMRO-E. 

• Promulgate a local instruction or operating procedure to implement the precious metals 
recovery program and require maintenance of auditable records of material collected and 
turned in to DPDO/DPDPMRO-E. 

• Provide copies of instructions, procedures and correspondence relative to local participation 
in the PMRP to NAVMEDMATSUPPCOM, 3500 S. Broad St., Philadelphia, Pa. 19145.— BU- 
MED Instruction 4010.2 of 14 Feb 1978. 

Controlled- substance inventory 

MANMED chapter 21 and the Comprehensive Drug Abuse and Control Act of 1970 direct 
specific controls over narcotics and controlled substances through audits, inventories, and 
security measures. However, the need for improved methods to ensure the security of these 
items is recognized. Comments on deficiencies in this area are repeatedly made by the Naval 
Audit Service; the Inspector General, Medical; the Joint Commission on Accreditation of Hos- 
pitals; and other agencies. 

In addition to the requirements prescribed by MANMED chapter 21 and the Comprehensive 
Drug Abuse and Control Act of 1970, the following actions are directed: 

• Schedules I and II drugs, and Schedule III narcotics, alcohol, and alcoholic beverages will be 
inventoried monthly by the Controlled Substance Inventory Board without advance notice. 

• Quality-control measures shall be established on all locally compounded products contain- 
ing controlled substances. Periodic analyses of products containing narcotics shall be per- 
formed. 

• Completed prescriptions shall be checked, at random, to ensure that they correctly corre- 
spond, both in quantity and substance, with their labels and their written prescriptions.— BU- 
MED Notice 6710 of 4 May 1978. 

Volume 69, July 1978 5 



Scholars' Scuttlebutt 



Clerkships at Navy Medical Facilities 



Summer is upon us, and with it a 
surge in active duty for training 
orders. Navy scholarship students 
may serve their ACDUTRA period 
at other times during the year, but 
most enter ACDUTRA assignments 
in the summer quarter. 

Some of you will be serving your 
ACDUTRA period this summer in 
clinical or research clerkships at 
Navy medical facilities. These clerk- 
ships are often your first contact 
with the Navy, and we are well 
aware that your experiences during 
this time will have a lasting effect 
on your view of the Navy health care 
system as a potential career vehicle. 
Therefore, we make clerkship train- 



ing meaningful from the military as 
well as the professional point of 
view by devoting significant parts of 
the curriculum to active naval ser- 
vice and to military health care. 
Clerkship clinical rotations and re- 
search experiences are carefully 
planned to fulfill your professional 
and academic requirements, within 
the training command's resources 
and mission. 

Clerkship programs are conduct- 
ed at naval regional medical and 
dental centers, naval hospitals, and 
Medical Department research activ- 
ities in the United States and Puerto 
Rico that have the required training 
capabilities. Generally, first-year 



and second-year students will not 
be assigned to clinical clerkships; 
however, third-year and fourth-year 
students are eligible for both clini- 
cal and research clerkships. Clerk- 
ships are assigned according to the 
quotas established at training sites. 
Scholarship students will receive 
information on clerkships from the 
Naval Health Sciences Education 
and Training Command. 

The first receipt of ACDUTRA 
orders can be a dismaying event. To 
cast some light on the subject, we 
offer an annotated set of ACDUTRA 
orders at right. A more detailed de- 
scription of your assignment will be 
provided with your orders. 




STUDENTS ON TOUR . . . Navy recruiters recently arranged for medical students at the University of Ari- 
zona to tour San Diego area installations. Here, at NAS Miramar, they hear a lecture on aviation medicine. 



U.S. Navy Medicine 



■ THESE ORDERS ARE ISSUED BV THE COMMANDING OFFICER, 
NAVAL HEALTH SCIENCES EDUCATION AND TRAINING 
COMMAND (NHSETC), LOCATED AT THE NATIONAL NAVAL 
MEDICAL CENTER (NNMC), BETHESDA, MARYLAND. 
YOU ARE ATTACHED TO THIS UNIT 



YOUR GRADE, NAME, AND ADDRESS. 
MAKE SURE HSETC CODE 9 
HAS YOUR CURRENT ADDRESS SO 
YOU GET ORDERS PROMPTLY 



ACDUTRA LASTS 45 DAYS - 



PHYSICAL EXAM FORMS 88 AND 93 ■ 
MUST BE COMPLETED BEFORE 

REPORTING FOR DUTY 



MAKE YOUR OWN TRAVEL - 
ARRANGEMENTS. 
REIMBURSEMENT IS ON 
A RECEIPT BASIS. 



NAVAL FINANCE CENTER (HFC 

CLEVELAND, OHIO, 

STOPS STIPEND DURING ACDUTRA 



DO ROT BUY A UNIFORM 
BEFORE FIRST ACDUTRA. 
REPORT IN JACKET AND 
TIE. UNIFORM 
INFORMATION GIVEN 
AFTER YOU REPORT. 



ACDUTRA ORDERS (formerly NBVPERS 1S71/5 [2-731/ 

-JAVRC5 1571/5 {10-75) NQVCOMPT 3120 (Key 3-72) 



■'Mtm«ffl?»56 K, «=TOCeRVWj5W?L HEALTH SCIENCES EDUCATION AND 
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ACCORDING TO PUBLIC LAW 92-426, 
ALL ENSIGNS, REGARDLESS OF 
PRIOR SERVICE, ARE PAID IN 
OFFICER GRADE {1 (0-1) DURING 
ACTIVE DUTY FOR TRAINING. 



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Detach on '-s august /976. 

■ SEE ATTACHMENT FOR TRAVEL INSTRUCTIONS AND REflUIREMENTS FOR PHYSICAL EXAM -[PHYSICAL EXAf! 
TO BE CONDUCTED IN ACCORDANCE WITH CAHPTER B, AR 40-501. 





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-FOR NFC CLEVELAND - STOP STIPEND ON 3d -JUW jq7C 

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^THE WEARING OF THE UNIFORM IS REQUIRED 



SIGNATURE OH ISSU'NC. OFFICER 

G- S- BAKER 

LTJG riSC USNR 

BY DIRECTION OF THE 

COIWANBING OFFICER 



-YOUR SERVICE DESIGNATOR 
IS ENSIGN 1975 



-SOCIAL SECURITY NUMBER 




-OH JULY 1, 1976, AT 8 AM, 
REPORT TO THE SPECIFIED 
COMMAND 



-ACCOUNTING INFORMATION 




■PHYSICAL EXAM IS NECESSARY 

TO REPORT FOR ACDUTRA 



HAVE THE OFFICER OF THE 
DECK (00D) SIGN YOUR 
ORDERS ON ARRIVAL 



LIVING EXPENSES (PER DIEM) 
AUTHORIZED UP TO THIS AMOUNT. 
REIMBURSEMENT IS ON A RECEIPT 
BASIS. YOU ARE NOT ELIGIBLE IF 
BACHELOR OFFICER QUARTERS (BOO) 
ARE AVAILABLE. 



Annotated Active Duty for Training Orders 



Volume 69, July 1978 



Notes & Announcements 



Dental continuing education courses . . ■ The following 

dental continuing education courses will be offered in 
September 1978: 

U.S. Army Institute of Dental Research, Walter Reed Army Medical 
Center, Washington, DC. 
Current Concepts of Restorative Dentistry 11-14 Sept 1978 



Letterman Army Medical Center. San Francisco. Calif. 



Removable Prosthodontics 



18-21 Sept 1978 



The National Naval Dental Center, Bethesda, Md. 
20014, has scheduled the following continuing educa- 
tion courses for the academic year 1978-1979: 



Operative Dentistry 

Oral Surgery 

Oral Diagnosis and Treatment Planning 

Preventive Dentistry and Patient Motivation 

Endodontics 

Comprehensive Dentistry 

Oral Pathology 

Removable Partial Dentures 

Periodontics 

Fixed Partial Dentures 

Complete Dentures 

Occlusion 

Fleet and Marine Support Operational 

Management Seminar 
Maxillofacial Prosthetics 



2-4 Oct 1978 

16-18 Oct 1978 

30 Oct- 1 Nov 1978 

13-16 Nov 1978 

4-6 Dec 1978 

11-14 Dec 1978 

8-12 Jan 1979 

22-24 Jan 1979 

5-7 Feb 1979 

26-28 Feb 1979 

12-15 Mar 1979 

2-4 Apr 1979 

16-20 Apr 1979 
30 Apr-2 May 1979 



The Director, Dental Activities, Eleventh Naval Dis- 
trict, has scheduled the following continuing education 
courses for 1978-1979 at the Naval Regional Dental 
Center, San Diego, Calif. 92136: 

Oral Diagnosis 2-4 Oct 1978 

Endodontics 16-18 Oct 1978 

Operative Dentistry 6-8 Nov 1978 

Fixed Partial Dentures 4-6 Dec 1978 

Removable Partial Dentures 8-10 Jan 1979 

Oral Pathology 22-26 Jan 1979 

Maxillofacial Prosthetics 29-31 Jan 1979 

Complete Dentures 20-22 Feb 1979 

Occlusion 12-14 Mar 1979 

Oral Surgery 2-6 Apr 1979 

Preventive Dentistry and Patient Motivation 23-26 Apr 1979 

Periodontics 14-16 May 1979 

All continuing education courses sponsored by the 
Dental Division, Bureau of Medicine and Surgery, are 
approved for dental relicensure credit with the Board of 
Dental Examiners for the following states: California, 
Iowa, Kansas, Kentucky, Massachusetts, Minnesota, 
New Mexico, North Dakota, Oklahoma, Oregon, South 
Dakota. 



Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 



Continuing education for Navy nurses . . . The Naval 

Health Sciences Education and Training Command will 
sponsor the following continuing education course for 
Navy nurses: 

Alcoholism, the Problem, its Ramifications, and Treatment 
(18 contact hours) 

17-19 Sept 1978 NRMC Long Beach, Calif. 

It is estimated that 50% of hospitalized patients have alcohol- related 
illnesses. This three-day program for general staff nurses will provide 
a basic knowledge of alcoholism and behavioral aspects of the alco- 
holic; the nurse's role in recognizing the condition when it is an un- 
derlying factor in other medical problems; and alcoholism's impact on 
the individual, his family, and the community. The nurse will com- 
pare treatment modalities and resources for rehabilitation. 

The course is open to Nurse Corps officers not cur- 
rently assigned to an oversea billet. However, nurses 
assigned to Argentia, Newfoundland; Bermuda; Guan- 
tanamo Bay, Cuba; Keflavik, Iceland; and Roosevelt 
Roads, Puerto Rico, who have served at least six 
months on active duty, may apply. The course is also 
open on a space-available basis to Nurse Corps officers 
of the inactive Reserve. 

Nurse Corps officers wishing to attend the course 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval Medi- 
cal Center, Bethesda, Md. 20014, following procedures 
set forth in the BUMED Instruction 4651.1 series. Ap- 
plications should be submitted four to six weeks before 
a course begins. 



Lab animals pathology course . . .The Armed Forces 
Institute of Pathology (AFIP) will offer a Pathology of 
Laboratory Animals course 11-15 Sept 1978 in Wash- 
ington, D.C. Military and federal service employees in 
the veterinary field and other medical science fields are 
requested to consult their agency regulations for appro- 



U.S. Navy Medicine 



priate application procedures. Civilian veterinarians 
and allied scientists are invited to apply and will be con- 
sidered on a space-available basis. Nonfederal and 
foreign national registrants are required to pay a $125 
fee, payable to the Treasurer of the United States. 

Applications should be submitted before 8 Aug 1978 
to: The Director, Armed Forces Institute of Pathology, 
ATTN: AFIP-EDZ, Washington, D.C. 20306. 

Health care administration class graduates . . . Thirty - 
two Medical Service Corps officers and two Coast 
Guard warrant officers graduated from the Naval 
School of Health Care Administration, NNMC, Bethes- 
da, Md., on 1 June 1978. The ceremony marked the 
39th consecutive year of the health care administration 
program and the 6th year of direct affiliation with The 
George Washington University's Department of Health 
Care Administration. 

The Surgeon General's Award for Scholastic Achieve- 
ment was awarded to LTJG Stephen C. Rice (MSC), 
who completed the program with a 4.0 cumulative 
average. LT Layton 0. Harmon (MSC), nominated by 
both staff and students, was selected for outstanding 
military leadership and was presented the Command- 
ing Officer's Award. 

Colon and rectal surgery symposium ... A symposium 
on "Colon and Rectal Surgery" will be held 27-29 Sept 
1978 at the National Naval Medical Center. For details 
write to: Administrative Assistant, Department of 
Surgery, National Naval Medical Center, Bethesda, 
Md. 20014. 

Joint conference on occupational health . . . The Ameri- 
can Academy of Occupational Medicine (AAOM) and 
the American Academy of Industrial Hygiene (AAIH) 
will hold a joint conference 19-22 Sept 1978 at the Wil- 
liamsburg Lodge, Williamsburg, Va. More than 500 
occupational physicians, industrial hygienists and other 
professionals interested in the health of workers will 
attend the meeting, which will focus upon aspects of 
medical-record keeping and surveillance important to 
the occupational health Field. Representatives from 
medicine, government, industry, and academia will 
present their viewpoints on "Significance of Data Col- 
lection," "Basic Concepts of Data Collection," "Man- 
datory Environmental and Medical Monitoring: Essen- 
tial?," "Special Problems in Performing Occupational 



Epidemiology Studies" and "Epidemiology." 

The regular scientific sessions on 20-22 Sept 1978 will 
be preceded by two postgraduate seminars on 19 Sept 
1978. The topics will be "Basic Computer Science Tech- 
niques for Occupational Health Physicians and Indus- 
trial Hygienists" and "Basic Concepts in Epidemiology 
for Occupational Health Physicians and Industrial 
Hygienists." 

Registration fees for the joint conference will be $35 
for AAOM and AAIH members and $45 for nonmem- 
bers. Postgraduate seminar fees will be $60 per 
seminar for AAOM and AAIH members and $80 for 
nonmembers. 

Members of AAOM and AAIH will receive advance 
programs through the mail. Nonmembers may obtain 
advance programs and registration information by 
writing to: American Academy of Occupational Medi- 
cine, 150 North Wacker Drive, Chicago, 111. 60606. 

Maxillofacial-injnry text ... An estimated 10%-15% of 
war wounds involve the highly complex maxillofacial 
area. Yet, when the Vietnam conflict began, oral sur- 
geons had available to them no contemporary single- 
source document on management of jaw-injured pa- 
tients. 

A new book from the Dental Sciences Department of 
the Naval Medical Research Institute is designed to fill 
that gap. Management of War Injuries to the Jaws and 
Related Structures, edited by CAPT James F. Kelly 
(DC), is based on a 10-year survey of selected Vietnam 
wounded who were followed through all phases of 
casualty care: early treatment in Vietnam, intermediate 
care at facilities along medevac routes, and reconstruc- 
tive-rehabilitative care at primary military hospitals 
and other federal or civilian facilities. 

The book's conclusions are drawn both from the sur- 
vey data and from the clinical experience of the contrib- 
utors: oral surgeons who served aboard hospital ships 
and in military medical facilities in Vietnam and Guam 
during the period of conflict. "As a result," says the 
editor, "their experiences have been passed on to those 
surgeons who in the future will have to deal with the 
complicated and often tragic circumstances of war casu- 
alty treatment." 

The 273-page book, profusely illustrated with draw- 
ings and color and black-and-white photographs, is 
available for $12 from the Superintendent of Docu- 
ments, U.S. Government Printing Office, Washington, 
D.C. 20402. 



Volume 69, July 1978 




Medical Practice at Sea 



CDR Leslie C. Ellwood, MC, USN HMC Ronald B. Littlejohn, USN 



What knowledge and technical 
skills are required of a physi- 
cian assigned to a deployed 
U.S. Navy ship? 

This is a question asked by all 
facing that duty. "Will I be able to 



CDR Ellwood was assigned to the USS 
Inchon (LPH-12) for four months of Mediter- 
ranean deployment. His usual assignment is 
as pediatrician, VADM Joel T. Boone Clinics, 
NRMC Portsmouth. Va. 23718. HMC Little- 
john, a medical services technician, is Senior 
Hospital Corpsman Chief of the Inchon and 
Medical Department representative in the 
absence of an assigned medical officer. 



10 



handle it?" is the unvoiced fear or 
most. 

Those who have completed their 
sea tour will reassure you, and this 
report will provide some data, from 
one ship's experience, on which to 
base that reassurance. 

The ship is the USS Inchon (LPH- 
12), an amphibious assault helicop- 
ter carrier, and during the five- 
month period this report covers (15 
April to 15 September 1977), she 
was deployed in the Mediterranean 
Sea. 

Three major units were assigned 
to the Inchon: the ship's company. 



Marine Battalion Landing Team 2/6 
(BLT 2/6) companies, and Helicop- 
ter Marine Medium Squadron 261 
(HMM-261). The ship's company 
numbered 610 men, the Marine de- 
tachments 848, for a total of 1,458. 
The Inchon's Medical Department 
also provided medical care for sail- 
ors and marines aboard other am- 
phibious squadron ships that had no 
medical officers. 

Our Medical Department staff in- 
cluded a single-manager TAD phy- 
sician as ship's GMO and Medical 
Department head, a flight surgeon 
with HMM-261, and a Marine bat- 

U.S. Navy Medicine 





TABLE 1. Summary of Medical Services Provided 






Medical Service 


Source of Data 


Population Base 


Number per 100 
men per month* 


Clinic visits 


Navy health records 
Inchon monthly statistics 


300 
1,458 




72.0 
67.0 




New illnesses 


Navy health records 


300 




46.0 




Inpatient admissions 


Inpatient admissions of men 
from USS Inchon 


610 
848 


(Navy) 
(USMC) 


0.5 

0.6 


(Navy) 
(USMC) 


Acute surgical or 
trauma admissions 


Inpatient records of men 
from USS Inchon 


610 
848 


(Navy) 
(USMC) 


0.1 
0.2 


(Navy) 
(USMC) 


Medical and NP admissions 


Inpatient records of men 
from USS Inchon 


610 
848 


(Navy) 
(USMC) 


0.4 
0.4 


(Navy) 
(USMC) 


Medevac or'transfer to 
shore facility 


Inpatient records of men 
from USS Inchon 


610 

848 


(Navy) 

(USMC) 


0.25 (Navy) 

0.2 (USMC) 


Prescriptions 


Total prescriptions issued 


1,458 




57.0 




X-ray procedures 


Total procedures 


1,458 




8.0 




Lab procedures 


Total procedures 


1,458 




25.0 




Venereal disease treatment 


Penicillin injection usage 


1,458 




0.6 




'Statistics allow for application to other deployed ships. 






talion surgeon. Hospital Corps per- 
sonnel numbered 11 for the ship's 
company, 20 for the BLT 2/6 
companies, and 2 for the helicopter 
squadron. There were also 2 dental 
officers and 3 dental technicians. 

An LPH has medical evacuation 
as one of its potential missions; 
therefore, the facilities and equip- 
ment can provide a broad range of 
medical services. The medical 
spaces include two surgery rooms 
(usually used as sick-call treatment 
areas); an X-ray unit that can pro- 
vide all routine radiological views; a 
laboratory (capable of CBCs, uri- 
nalyses, cultures and sensitivity, 
darkfield exams, and RPR, Mono- 
spot, NA, K, glucose, BUN, biliru- 
bin, and SGOT determinations); 
and a 20-bed ward. (An additional 
66 beds are available if medical 
evacuation is ever required.) 

Special equipment available to 
us included an EKG and a Lifepak R 
resuscitator, physiotherapy tanks, 
two orthopedic beds, eye refraction 
equipment, and most major and 
minor surgical packs. In addition, 

Volume 69, July 1978 



the most commonly used pharma- 
ceuticals, intravenous solutions, 
and parenteral medications were 
stocked. 

Medical services provided aboard 
the Inchon during the Five-month 
period are summarized in Table 1. 
A review of medical charts on the 72 
patients admitted to the medical 
ward during the period provided in- 
patient data for this study. Outpa- 
tient data and population statistics 
were derived from a review of the 
military health records of 300, or 
50%, of the ship's company (every 
other record in the file was selected 
for review). Other data came from 
the Medical Services and Outpa- 
tient Morbidity Report, NAVMED 
6300/1 (6-61), which provides 
monthly patient care statistics. 

The composition of the ship's 
company was 67% E-l to E-4, 26% 
E-5 to E-9, and 7% commissioned 
and chief warrant officers. The av- 
erage age of the 300 crewmembers 
whose health records were reviewed 
was 23.8 years, with a range of 17 to 
52 years, and 53.3% were between 



17 and 21. Population statistics for 
the embarked Marines were not ob- 
tained. 

In Table 1, the total figures for 
medical services required by the 
Navy crew and embarked Marines 
have been reduced to a common 
factor: number of services provided, 
per 100 men aboard, per month. 
The source from which the data is 
derived and the population on which 
the calculation is based are noted in 
the table's third and fourth col- 
umns. 

From the monthly statistics re- 
ported on NAVMED 6300/1, we 
derived an average of 447 sick-call 
visits a month for Navy men and 536 
visits for Marines. From our study 
of the 300 health records we found 
that sailors from this group made 
1,100 clinic visits, with 697 different 
illnesses, during the five-month 
period. Projecting for the total of 
610 Navy crewmembers, we would 
predict 440 visits per month by 
Navy personnel. 

The Navy men averaged 1.6 visits 
for each illness. From the 300 health 



11 



records reviewed, we found that 
18% of these men never visited 
the clinic in the five-month period 
studied; 15.3% made only one visit; 
26.6% made two to three visits; and 
40% made four or more. Age or 
rank made no significant difference 
in clinic usage rate. 

The distribution of types of out- 
patient illnesses recorded in the 300 
health records is reported in Table 
2. Respiratory and ear complaints, 
trauma, and skin disorders were the 
most common problems and ac- 
counted for 64.6% of all outpatient 
illnesses. None of the fractures re- 
quired more than closed reduction 
and casting; lacerations were all 
superficial. The majority of the 
illnesses were handled by the hos- 
pital corpsmen. The physicians per- 
formed physical examinations; 
handled cases for which X-rays, 
antibiotics, or controlled drugs were 
indicated; and cared for patients 
with more severe illnesses or in- 
juries, with chronic or recurring 
problems, and with need for psy- 
chological counseling. 

Seventy-two patients were ad- 
mitted to the Inchon's medical ward 
during the five-month period: 16 
Navy crewmembers and 26 Marines 
from the Inchon, 8 men from NATO 
Forces temporarily assigned to the 
Inchon, and 22 sailors and Marines, 
from other ships. Seventy-six per- 
cent of the men admitted were 
under 23 years of age; 77% were 
E-4 or under in rank. 

Table 3 summarizes inpatient ex- 
perience during the five-month 
period studied. None of the physi- 
cians assigned to the Inchon during 
this period performed elective major 
surgery, but surgeons assigned to 
other LPHs reportedly have chosen 
to do so. One appendectomy, under 
spinal anesthesia, was performed 
by LT Braden. MC, USNR, the 
HMM-261 flight surgeon, and LT 
Carron, MC, USNR, from the USS 
Seattle. 

Admissions to the Inchon's medi- 
cal ward were often determined by 
factors other than medical indica- 
tion. In several cases, men from 
crowded berthing spaces could 




TABLE 2. Distribution of Outpatient Illnesses 
During 5-Month Deployment 



Illness Category 



Percentage of 
New Illnesses 



Respiratory and ear complaints 

Acute orthopedic complaints {sprains, bursitis, 

tendinitis, low back pain, muscle strain, fracture) 15.4 
Lacerations requiring suture 5.1 

Soft tissue trauma (abrasions, contusions, burns) 4.3 

Skin disorders (nonspecific rashes, scabies, 

eczema, tinea, acne) 
Psychological counseling and substance abuse 
Gastrointestinal complaints 
Physical examinations (annual or special) 
Genitourinary complaints (includes NSU) 
Eye complaints and routine refractions 
Superficial cellulitis and abscess 
Chronic orthopedic and non-acute surgical problems 
Headaches or concussion 
Venereal disease (syphilis and gonorrhea) 



27.5 



24.8 



12.3 
7.0 
6.8 

5.7 
4.0 
3.7 
3.4 
2.3 
1.9 
0.6 



more easily receive necessary treat- 
ment as inpatients than as outpa- 
tients, and men with chronic medi- 
cal-surgical or neuropsychiatric 
problems were admitted to facilitate 
medevac or transfer to shore facili- 
ties. 

Forty-nine of the 72 admitted pa- 
tients, or 68%, were returned to 
duty with their respective units 
upon discharge. The rest underwent 
medevac or were transferred to 
shore medical facilities in the 
Mediterranean or in Germany. In- 
patient length -of- stay (LOS) aver- 
aged 3.5 days for all admissions and 
3.8 days for medevac and transfer 
patients. LOS was 3.0 days for those 
medevac patients who eventually 
needed emergency medical facility 
services, but no complications re- 
sulted from the delays in transfer. 

Forty-seven Navy and Marine 
Corps members were treated on an 
outpatient basis for venereal dis- 
ease (including primary syphilis, 
gonorrhea, lymphogranuloma vene- 
reum, and nonspecific urethritis). 
The recommended treatment regi- 
men was followed in each case, and 



no penicillin-resistant strains of 
Neisseria gonorrhoeae were noted. 
Contact interviews and reporting 
were done by a senior hospital 
corpsman. 

Although the potential for medical 
crisis aboard deployed ships al- 
ways exists, medical practice 
during this deployment most often 
involved commonplace illnesses 
well within the competence of most 
Navy clinical physicians. Traumatic 
injury is common as a result of work 
environment, but injuries are rarely 
serious or life threatening. The 
amount of surgery performed is de- 
termined solely by the individual 
desire of the physicians. Medical 
evacuation is available for patients 
who require care beyond the ship's 
capabilities or the physicians* skills. 
Although the medevac system 
seems slow to the concerned physi- 
cian at sea, most patients will tol- 
erate the delays if general principles 
of supportive care are followed. 

The orientation courses for pro- 
spective ship's doctors emphasize 
sanitation, pest control, and the 



12 



U.S. Navy Medicine 



TABLE 3. Inpatient Experience During 5-Month Deployment 



Diagnosis 



Total Percentage Comments 



Acute trauma 19 

Medical illnesses 19 

Surgical problems 11 



26.4 
26.4 

15.2 



Superficial skin or 
lymphatic infec- 
tion 9 

Neuropsychiatric 14 



12.5 
19.4 



7 orthopedic; 7 severe lacerations; 
3 head trauma; 2 burns 

9 respiratory; 6 gastrointestinal; 

2 oxygen toxicity; 1 genitourinary; 
1 myocardial infarction 

3 acute appendicitis (2 medevac; 
1 appendectomy performed on 
Inchon); 5 chronic surgical admitted 
for medevac; 2 pilonidal cysts 
drained; 1 pneumothorax required 
chest tube 



Admitted for medevac or transfer 

to shore facility 



preventive aspects of sea medicine. 
These are indeed important ele- 
ments of the medical officer's du- 
ties, and you must be knowledge- 
able about them; however, much of 
the actual performance of these 
duties can be delegated to properly 
trained Hospital Corps staff. The 
major responsibilities of the medical 
officer are supervision for quality 
control and the communication or 
interpretation of findings to other 
ship's departments — or to Com- 
mand — so that they will take appro- 
priate preventive or corrective ac- 
tion. 

Several other areas of concern oc- 
cupied significant amounts of the 
Inchon medical officers' time. These 
included substance abuse, psycho- 
logical counseling, and education. 

Drug abuse during liberty and 
while at sea is a problem for all 
Navy ships. During the deployment 
under discussion, the Mediter- 
ranean ports provided a constantly 
accessible source of Quaalude, am- 
phetamines, Valium, marijuana, 
and hashish. These drugs were 
used by a significant proportion of 
younger crewmembers (E-4 and 
below). 

Most of the chronic drug abusers 



exhibited immature, inadequate, 
and passive-aggressive personali- 
ties. Almost all admitted using 
drugs before their enlistment 
(though they did not report this at 
the time of enlistment), and most 
came from families in which com- 
munication and satisfaction of emo- 
tional needs were poor. Prior to 
their eventual identification as drug 
abusers, most of these servicemen 
had made repeated visits to sickbay 
with numerous psychosomatic com- 
plaints and had been reported by 
their departments to be poor per- 
formers at work. 

While drug counseling was avail- 
able at the Human Resources Man- 
agement Detachment in Naples and 
at the Counseling and Assistance 
Center at Rota, effective treatment 
required the personal interest and 
efforts of our medical officers and 
hospital corpsmen in diagnosis, 
counseling, and administrative 
preparations for referral. Knowl- 
edge of adolescent psychology was 
beneficial. 

Despite constant admonitions, 
risk of liberty restrictions, and dis- 
ciplinary actions, alcohol abuse was 
a problem during liberty or work 
port visits. The Medical Depart- 



ment was involved in repair of in- 
juries sustained by intoxicated ser- 
vicemen, examinations for confine- 
ment of the violent drunk, ward 
admissions of the near comatose, 
administration of medication to the 
agitated drunk, and testimony on 
medical observations at disciplinary 
masts. 

It was the practice of the Inchon 
Medical Department to note in the 
health record all instances of alcohol 
abuse (by enlisted men and officers) 
brought to our attention. When fol- 
lowup interview or counseling indi- 
cated problem drinking or possible 
alcoholism, this fact, and a recom- 
mendation for the appropriate level 
of alcohol counseling or therapy, 
was reported in a memorandum to 
the patient's command. 

An Alcohol Rehabilitation Unit 
was available at NRMC Naples, and 
an Alcohol Rehabilitation Drydock 
at Rota accepted men for briefer 
therapy. For patients who were fol- 
lowed closely by the Medical De- 
partment with counseling, CODAC 
referral, and antabuse, therapy was 
delayed for CONUS centers at the 
end of deployment. 

We found that a large percentage 
of sick-call complaints were psy- 
chosomatic. The stresses of ship- 
board life and work, aggravated by 
deployment separations and im- 
mature personalities, take their toll, 
and the Medical Department is a 
place where grievances can be 
aired. Rarely, however, do young 
servicemen report psychological 
stresses unless the corpsman or 
doctor looks beyond the presenting 
complaint. Medical Department 
personnel with an inclination to 
listen, counsel, and intercede for 
these troubled men can perform a 
significant service to morale. 

Education, both for hospital 
corpsmen and the ship's crew, is 
another task that demands much 
attention from medical officers. The 
ship's training requirements assign 
to the Medical Department such 
topics as nuclear, biological and 
chemical warfare decontamination, 
first-aid and casualty evacuation, 
preventive health measures, and 



Volume 69, July 1978 



13 



venereal disease. Medical officers 
with special interests and skills are 
allowed to provide any additional 
training they desire. 

Means available to us for provid- 
ing medical information to the crew 
included closed-circuit television 
lectures, group lectures fay corps- 
men or physicians, and the ship's 
Plan of the Day (we had a daily 
"Doc's Advice" entry in the POS). 

An inservice educational program 
for Hospital Corps personnel is es- 
sential to maintain and broaden 
their skills. The chief petty officers, 



independent duty corpsmen, and 
Hospital Corps technicians can 
share their specific knowledge for 
the benefit of the general duty 
corpsmen and themselves. The 
medical officers also provide in- 
struction in general medicine and 
their specific areas of expertise. 

An assignment as medical officer 
of a deployed Navy ship is within 
the competence of most clinical 
Navy physicians. 

Although "surgical skills" are 
usually thought to be the most de- 



sirable, the abilities required during 
this deployment were primarily 
minor surgical skills, general out- 
patient medicine, routine inpatient 
care, psychological counseling, and 
an understanding of preventive 
health measures. 

In numerous areas, concerned, 
hard-working physicians and hos- 
pital corpsmen can contribute to 
better physical and mental health 
aboard ship. The deployment expe- 
rience, in turn, will broaden and 
enrich each physician so that he be- 
comes a better Navy doctor. 



Shipboard Medicine: 'An Ounce of Prevention 



Days lost from duty because of illness or accident re- 
sult in the impaired operational effectiveness of naval 
units, just as sick days result in production losses in in- 
dustrial settings. A high standard of medical care, in- 
cluding active prevention, is an essential element in 
sustaining crew effectiveness. Such prevention, in turn, 
depends on the identification of situational factors that 
lead to increased morbidity. 

In "Morbidity as a factor in the operational effective- 
ness of combat ships," published in the August 1977 
issue of Military Medicine, J.M. Erickson, L.M. Dean, 
and E.K.E. Gunderson report on efforts to determine 
causal factors of illness on combat ships. In a study of 
shipboard illness, research staff of the Naval Health 
Research Center, San Diego, boarded five destroyer 
escorts early in their deployments to the Western Pacif- 
ic to investigate these factors. 

Specially designed individual data cards were used to 
record all sick-call visits for the length of the deploy- 
ment. The purpose of the card was to obtain better 
standardization and a more complete recording of each 
illness episode than was possible with routine reporting 
procedures. The specific conditions or illness categories 
on the card were identical to those used on the Monthly 
Outpatient Morbidity Report submitted to BUMED by 
all ships. This format was chosen because hospital 
corpsmen are familiar with the illness categories and 
because use of the cards would facilitate preparation of 
the Monthly Outpatient Report and serve as an incen- 
tive for accurate recording. 

When illness episodes were analyzed, trauma and 
gastrointestinal disorders accounted for a substantial 
number of the days lost during deployment. It was 
found that gastrointestinal infections were most likely 
to occur when ships were in port. Accidents and trau- 
ma were likely to occur any time, at sea or in port. 



There tended to be large differences in trauma rates 
between petty officer and non-rated groups. Lower- 
rated men, inexperienced in their jobs and unfamiliar 
with the shipboard environment, had many more in- 
juries than petty officers, particularly in the first 
quarter of the deployment. 

The incidence rate for gastrointestinal disorders for 
non-rated men was only slightly higher overall than 
that for rated men, and there were no consistent differ- 
ences between quarters of deployment. Thus, pay 
grade or experience was an important factor in trauma 
but a negligible factor in GI disorders. 

The incidence of gastrointestinal disorders was found 
to be primarily a function of specific ports visited. Ex- 
amination of GI illness rates during and immediately 
following visits to Western Pacific ports indicated that 
two ports presented relatively high risks for GI dis- 
orders. For example, one ship had a total of 52 initial 
dispensary visits for gastrointestinal illness after visit- 
ing one of these ports. Two officers, 10 petty officers, 
and more than 20 enlisted men were placed on the dis- 
abled list. It is clear that this ship was forced to operate 
at a decreased level of effectiveness for a short period 
because of the GI epidemic experienced in this port. 

In order to plan adequate medical support for fleet 
operations, a forecast model for casualties during 
operational deployments appears essential. The Naval 
Health Research Center is currently developing such a 
model, designed to help commanding officers and med- 
ical personnel be alert to environmental and operational 
conditions that might adversely affect crewmembers 
and thus impair ship effectiveness. 

For a reprint of the original article on morbidity and 
operational effectiveness, write: E.K. Eric Gunderson, 
Ph.D., Naval Health Research Center, San Diego CA 
92152. 



14 



U.S. Navy Medicine 



INIAVMED Newsmakers 



HM2 Elizabeth R. Burkhart has 

been a winner from the beginning of 
her naval career. This spring, she 
capped a series of honors by 
winning BUMED's nomination for 
the CNO's Shore Sailor of the Year 
competition. 

Petty Officer Burkhart, a 1971 
graduate of California State Univer- 
sity with a B.A. in physical educa- 
tion, enlisted in the Navy in January 
1973. Chosen Recruit Chief Petty 
Officer by her company command- 
er, she graduated from recruit train- 
ing with the American Spirit Honor 
Medal and was selected Honor 
Woman of her company. 

In Hospital Corps "A" School at 
Great Lakes, 111., she was Wave 
Platoon Leader of her company and 
graduated in the top 25% of her 
class. She was subsequently as- 
signed to Naval Hospital Orlando, 
Fla., where she was chosen Sailor of 
the Month for both the hospital and 
the Naval Training Center, and 
Sailor of the Year (1974) for the hos- 
pital. 

In April 1975, Petty Officer Burk- 
hart was transferred to the Naval 
Communications Station in Adak, 
Alaska, where, in off-duty hours, 
she pursued her sports interests as 
a member of the Adak Volleyball 
Team. The team won the 13th Naval 
District Championship in 1976 and 
traveled to Long Beach, Calif., for 
the All-Navy Championship. HM2 
Burkhart was selected that year for 
both the All-Navy and All-Service 
teams. 

In spring 1976, Petty Officer 
Burkhart began duty with the 
Patient Affairs Service at NRMC 
Long Beach, where she was named 
Sailor of the Quarter and Sailor of 
the Year in 1977. In February of this 
year, she picked up her second 
degree — a B.S. in health care ser- 
vices earned through Southern Illi- 
nois University. In her spare time, 



she works with handicapped chil- 
dren in Orange County, Calif. 

Says her commanding officer: 
"The honors garnered by this ex- 
ceptional individual attest to her 
desire for achievement and im- 
provement. . . . Her personal atti- 
tude of caring and sharing has a 
positive effect on all personnel and 
enhances the spirit of cooperation 
prevalent in her area. Petty Officer 
Burkhart is an unparalleled profes- 
sional, to whom excellence is not a 
goal, but a personal fiat." 

There's little anyone can add to 
that except congratulations — and a 
hearty 'well done." 

More honors: Hospital Corpsman 
William Bethards was the Medical 
Department member of a four-man 
search-and-rescue team from NAS 
Lemoore recently awarded medals, 
on behalf of President Carter, for 
"heroic achievement in aerial 
flight." The recognition resulted 
from a helicopter operation that 
plucked two injured climbers from a 
13, 000-foot -high ledge in the Sierra 
Nevada . . . The Medical/Dental 
Department of the USS Independ- 



Okinawa's Sailor of the year 





BUMED's Shore Sailor nominee 

ence (CV-62) was one of three de- 
partments aboard the aircraft car- 
rier to win a Battle Efficiency 
Award, after stiff competition with 
other Atlantic-based carriers . . . 
HM1 Allen E. Kasperbauer, of 
NRMC Okinawa, has been selected 
Okinawa's Sailor of the Year for 
1977, after competing with candi- 
dates from all the island's other 
naval commands . . . CAPT Robert 
E. Cassidy (DC) was named a "Citi- 
zen of the Year" by the Ohio State 
University Alumni Association . . . 
CDR Clarence H. Spence (MC) re- 
ceived an Alumni Merit Award from 
Marquette University . . . And, at 
the annual meeting of the Undersea 
Medical Society, CAPT William H. 
Spaur (MC) and CDR Edward T. 
Flynn, Jr. (MC), were joint recipi- 
ents of the Oceaneering Interna- 
tional Award in recognition of their 
contributions to diving medicine. 



Volume 69, July 1978 



16 



Career Pathways for Nurse Corps Officers 

Professional patterns are changing, but success 
still hinges on performance and initiative 



CDR Ann Langley, NC, USN, Nursing Division, BUMED 



Historically, the Nurse Corps has 
been a community of general- 
ists. "Career development" 
traditionally has meant serving in 
the widest possible variety of as- 
signments, to prepare for senior- 
level administrative positions with 
broad responsibility. 

While some generalists are still 
necessary, times are changing, and 
the Nurse Corps is adapting to the 
changes in health-care delivery. As 
a result of the information explosion 
and the growing sophistication of 
patient care, there is increased need 
for experienced Nurse Corps offi- 
cers with expertise in clinical spe- 
cialties and education as well as in 
administration. 

In recognition of the changing 
roles of nurses in Medical Depart- 
ment facilities, and of increasing 
specialization within the nursing 
profession, the Navy's classification 
system has been revised and ex- 
panded to describe more accurately 
the practice of professional nursing 
in today's Navy. All Nurse Corps 
officers have now been assigned 
subspecialty codes reflecting their 
educational background and experi- 
ence. Similarly, billet requirements 
have been revised to reflect the 
level of education and experience 



required as well as the functions to 
be performed. 

Figure 1 illustrates the profes- 
sional development patterns en- 
visioned for Nurse Corps officers. 
As indicated, Nurse Corps officers 
will continue to be assigned primar- 
ily to staff nurse and charge nurse 
positions in a variety of settings 
during their first few years of active 
duty. This will not only give the offi- 
cer a broad base in nursing but will 
also provide the opportunity for 
exposure to many of the potential 
career options available. 

After that point, Nurse Corps re- 
quirements fall into three major 
categories: clinical practice, admin- 
istration, and education and re- 
search. While some specialization 
will be necessary, a great deal of 
opportunity will still exist for lateral 
transfer among the three major as- 
signment areas. For example, pro- 
gressive assignments as staff nurse, 
charge nurse, and patient care co- 
ordinator can lead an officer into 
advanced clinical practice, into ad- 
ministration, or (after a preparatory 
assignment as an instructor) into a 
billet as an educational coordinator. 
The assignments in each pathway 
provide progressive responsibility 
and professional growth. 



Promotion opportunities are 
equal in each pathway. Examples of 
the types of positions available in 
each major assignment area are 
listed in Figure 1. The assignments 
shown are not all-inclusive, and 
your assignment to a particular 
position may not occur at the exact 
point in time indicated on the chart. 
The chart simply illustrates the 
general progression of assignments 
and promotion that can be expected. 

Figures 2 through 7 are examples 
of representative assignments with- 
in the three career development 
pathways. Many varied combina- 
tions of assignment are possible 
within each career pathway, and 
many opportunities exist to 
"change course" at different points 
along the way. You must remember, 
though, that if you change course 
you may have to acquire additional 
experience to prepare you for the 
responsibilities ordinarily assigned 
to someone of your grade and time 
in service in the new career pathway 
you select. 

The educational resources avail- 
able to the Nurse Corps are used to 
give individual officers the prepara- 
tion they need to fulfill Navy re- 
quirements. The column on the far 
right of Figure 1 shows the educa- 



te 



U.S. Navy Medicine 



FIGURE 1 . Nurse Corps Officer Professional Development Path 





25 




StU 




23 




22 




21 




20 


CAPT 






19 




16 




IT 




16 




15 


CDB 


ll4 




13 




12 




11 




10 


LOTR 


9 




8 




1 




6 




■> 




k 


LT 


3 




2 


LTJG 






1 


ENS 





ASSIGNMENT AREAS 



lfii_ 



CLINICAL PRACTICE 



ADMINISTRATION 



3 s 






O -rH -H 

eu o s 






V] S3 01 
< « 01 






CHARGE NURSE 
OVERSEAS 
HAVHOSF 

BRCLINTC 



ASST CHARGE NURSE 

STAFF HURSE 

CONUS MEDICAL CENTERS 



EDUCATION/RESEARCH 



3<3 



01 M 

v d 

t£ to 

£ S 

a, e 



EDUCATIONAL 

DEVELOPMENT 



! & 5 ft 



h iJ o J a 

h3h m 

„ H M R W 5= 

E &4 O ^ W 

< O W W «£ ij 

O P4 ffl W ■< 

w 5 ca tK 

An ^ W 3 a 

H U w «d 

en k o 

w >, u u 

tH < Q ffl 

to £ 1 



0RIEKTATI0H 
INDOCTRINATION 



tional programs available. All Nurse 
Corps officers receive officer indoc- 
trination training and basic orienta- 
tion to the hospital initially, and in- 
service and continuing education 
throughout their Navy careers. Se- 
lection for other programs is de- 
pendent on performance, experi- 
ence, the needs of the Navy, and the 
availability of funds. There are no 
hard-and-fast rules governing the 



timing of the various programs. The 
"right time" to consider advanced 
education will depend on your ex- 
perience and your career goals. 

Career development is a dynamic 
process, built on sound career coun- 
seling. And career counseling is a 
partnership — it is as much your re- 
sponsibility to seek it as it is your 
seniors' responsibility to provide it. 

Take an active role in your career 



development. Success in the Navy 
Nurse Corps is not dependent on 
any single factor — not a graduate 
degree, not a particular specialty, 
not a specific combination of assign- 
ments. The one universal factor in- 
fluencing a successful career is your 
performance as an individual and 
your ability to contribute effectively 
to the accomplishment of the mis- 
sion of the Navy Nurse Corps. 



Volume 69, July 1978 



17 



CAREER PATHWAYS (continued) 



FIGURE 2. Clinical Practice Example: Clinical 
Specialist in Medical /Surgical Nursing 



Years of 

Service 



Assignments 



1 - 3 Staff nurse, NRMC 

4-5 Charge nurse, overseas 

6 - 8 Clinical instructor, NRMC 

9-11 Charge nurse, ICU, NRMC 

12-13 DU INS— MSN in medical /surgical nursing 

14 - 16 Clinical specialist, NRMC 

17 - 19 Clinical specialist, graduate teaching hospital 

20-23 Senior clinical consultant, graduate teaching 
hospital 



FIGURE 3. Clinical Practice Example: 
Nurse Anesthetist 



Years of 
Service 



Assignments 



1 - 3 Staff nurse, NRMC 

4 - 5 Anesthesia school 

6 - 7 Staff CRNA, NRMC 

8-9 Independent duty 

10 - 12 Clinical instructor, anesthesia school 

13-14 Senior CRNA, NAVHOSP 

15-17 Clinical coordinator, anesthesia school 

18-20 Senior CRNA, NRMC 

21 - 24 Head, Nurse Corps Anesthesia School, HSETC 



FIGURE 4. Administration Example 



FIGURE 5. Administration Example 



Years of 

Service 



Assignments 



1 - 3 Staff nurse, NRMC 

4-5 Charge nurse, overseas 

6-8 Nurse Corps recruiting 

9-11 Outpatient care nurse, NRMC 

12 - 13 DUINS— MSN in nursing service administration 

14 - 16 Patient care coordinator, NRMC 

17-18 Chief of nursing service, NAVHOSP 

19-22 Staff, BUMED 

23-25 Director of nursing services, NRMC 



Years of 
Service 



Assignments 



1 - 3 Staff nurse, NRMC 

4- 5 Outpatient care nurse, BRCLI NIC 

6 - 8 Charge nurse, NRMC 

9-10 Patient care coordinator, overseas 

11-13 Patient care coordinator, NRMC 

14-16 Senior nurse, BRHOSP 

17-19 Associate director of nursing service, NRMC 

20 - 22 Chief of nursing service, NAVHOSP 

23-25 Director of nursing service, NRMC 



FIGURE 6. Education and Research Example 



FIGURE 7. Education and Research Example 



Years of 
Service 



Assignments 



1 - 3 Staff nurse, NRMC 

4-5 Charge nurse, overseas 

6-8 Nursing instructor, Hospital Corps School 

9-11 Nursing instructor, graduate teaching hospital 

12 - 13 DUINS— MSN in nursing education 

14 - 16 Nursing educational coordinator, NRMC 

17 - 19 Regional educational coordinator, NRMC 

20 - 23 Director, Nurse Corps Programs, HSETC 



Years of 
Service 



Assignments 



1 - 3 Staff nurse, NRMC 

4 - 5 Charge nurse, NAVHOSP 

6 - 8 Nursing instructor, NRMC 

9-11 Instructor, officer indoctrination school 

12 - 13 Nursing educational coordinator, overseas 

14-16 Curriculum development, HSETC 

17 - 19 Senior nurse, Hospital Corps school 

20-22 Regional educational coordinator, NRMC 



is 



U.S. Navy Medicine 



Professional 



Child Abuse as a Major Cause of Retardation 



ENS Samuel B. Hester, USNR 



In 1946, Caffey (/) first suggested that mistreatment 
of children by parents could be intentional. Interest in 
research in the area of child abuse gradually increased 
during the 1950's, and in 1962 Kempe et al. (2) intro- 
duced the term "battered child syndrome." The term 
was descriptive of characteristic fractures and subdural 
hematomas that appeared in X-rays at various stages of 
healing, indicating that they were sustained at different 
times, and seemed to be the result of force applied to 
the child's head, limbs, or body. 

This discovery resulted in an explosion of interest and 
concern among physicians and government agencies. 
An enormous amount of research has since been done 
on child abuse and has resulted in some protective 
legislation. Radio and television programs and news- 
paper articles have been devoted to the problem. None- 
theless, the idea that child abuse may be significantly 
related to mental retardation has not been thoroughly 
investigated. 

Robinson and Robinson (J) have stated that "child 
abuse is a widespread phenomenon and perhaps a 
major cause of retardation." Obviously, the fact that 
many children in this country are being abused should, 
in itself, be enough to persuade society to make a sus- 
tained, determined effort to prevent such occurrences. 
Often, however, only when a problem is viewed from 
the standpoint of dollars and cents will action be taken. 
Therefore, an attempt needs to be made to determine 
whether or not child abuse is a major cause of retarda- 
tion. If so, the financial savings to society that would be 
gained from preventing child abuse, or at least decreas- 
ing its incidence, should be obvious. 

Because of the absence of conclusive research, 
Brandwein (4) took a deductive-speculative approach to 
this problem. He addressed these questions: 

• What is the incidence of child abuse? 

• To what extent is child abuse associated with head 
trauma and brain damage? 

• Are head trauma and brain damage related to 
mental retardation? 

This paper will address itself to these same ques- 



ENS Hester is a doctoral candidate in clinical psychology at the 
University of Mississippi, Oxford, Miss. 38655. 



Volume 69, July 1978 



tions, in an attempt to corroborate and supplement 
Brandwein's speculations. In addition, it will address 
two important questions not discussed by Brandwein: 

• If child abuse and retardation are causally related, 
are they also linked to poverty and lower socioeconomic 
status? 

• Does cognitive impairment antedate abuse or is it 
one of its effects? 



Incidence of child abuse 

The actual incidence of child abuse is unknown. 
There are many reasons for the lack of reliable statistics 
— among them, differences in definition of the term, 
agency failure to report instances of abuse, and 
diminished likelihood that cases will be reported if the 
abuser is of sufficient income or status to be referred to 
a private practitioner rather than a public agency. 

Almost all reported cases have this characteristic in 
common: the injuries were severe enough that several 
sources agreed abuse had occurred. 

Available information strongly suggests that child 
abuse takes place far more frequently than one may 
naively imagine. Fontana (5) cites an editorial in The 
Journal of the American Medical Association which 
stated that maltreatment of children, if statistics were 
complete and available, could turn out to be a "more 
frequent cause of death than such well recognized and 
thoroughly studied diseases as leukemia, cystic fibro- 
sis, and muscular dystrophy, and may even rank with 
automobile accidents and toxic and infectious encepha- 
litis as causes of atypical disturbances of the central 
nervous system." 

A text on the battered child by David Bakan (6) noted 
that at least 6% of physicians belonging to the Hawaii 
Medical Association witnessed cases of child abuse in a 
year. These figures, according to Bakan, suggest that 
"we are dealing with a major social problem." 

According to Zalba (7), at least 200,000 to 250,000 
children in the United States need protective services 
each year. Of these, 30,000 to 37,500 require protection 
from serious physical abuse. 

Gil (8) describes a study conducted at Brandeis Uni- 
versity by the National Opinion Research Center 
(NORC) that attempted to explain prevailing attitudes 



1.9 



on physical child abuse in America and to obtain an in- 
direct estimate of the scope of this phenomenon. 

To determine incidence rates, respondents to the 
survey were asked whether they personally knew fami- 
lies that had been involved in incidents of child abuse, 
resulting in physical injury, during the 12 months pre- 
ceding the interview. Forty-five respondents — 3% of 
the 1,520 questioned — reported such personal knowl- 
edge. When sample proportions obtained in the survey 
were extrapolated to the total U.S. population, within a 
known margin of error, it was estimated that between 
2.53 and 4.07 million cases of child abuse had occurred 
during the year ending in October 1965, resulting in 
injuries ranging from minimal to fatal. This is an esti- 
mated annual child abuse rate of 13.3 to 21.4 incidents 
per 1,000 persons. Obviously, however, it is a very 
rough estimate, having been obtained by an indirect 
method, the validity of which is unknown. 

A text on the battered child edited by Heifer and 
Kempe (9) indicated that in 1967 tens of thousands of 
children in the United States were severely battered or 
killed, and that perhaps one or two children were being 
killed each day by their own parents. It was estimated 
that 15% of children under five years of age who are 
brought into hospital emergency rooms have been bat- 
tered. 

In a study of child-abusing parents that embraced a 
wide range of socioeconomic levels, Steele and Pollock 
(10) observed no concentration of cases in any one 
socioeconomic group. They reported: 

If all the people we studied were gathered together, they would not 
seem much different than a group picked by stopping the first several 
dozen people one would meet on a downtown street in a random 
cross-section sample of the general population. They were from all 
socioeconomic strata, laborers, farmers, blue-collar workers, white- 
collar workers, and top professional people. Some were in poverty, 
some were relatively wealthy, but most were in between. They lived 
in large metropolitan areas, small towns, and in rural communities. 

This finding is confirmed by Gil (8) and Fontana (5). 

One can see that there is much disagreement as to 
the actual incidence of child abuse in the United States. 
Nevertheless, most sources agree that the rate of inci- 
dence is alarmingly high and that there appears to be 
no class monopoly on child abuse. 

Head trauma and brain damage 

Available research suggests that child abuse is defi- 
nitely associated with head trauma and brain damage; 
however, the extent of this association is still a debated 
issue. 

Kempe et al. (2) reported the results of a nationwide 
survey of hospitals and law enforcement agencies. 
Within a one-year period, 749 children were reported to 
have been abused. Of this number, 78 children died 
and 114 suffered permanent brain damage. 

Kempe also indicated that the maltreatment of chil- 
dren was a particularly common problem in his hospital 



at the University of Colorado School of Medicine. On a 
single day, he stated, the pediatric service there was 
caring for four infants suffering from parent-inflicted 
physical injuries. 

Apthorp (II), at the Children's Hospital of Los An- 
geles, received 263 diagnosed cases of child abuse over 
an eight-year period. Of these children, 138 (approxi- 
mately 53%) had suffered head trauma, and in 79 of 
these cases the trauma was considered major. Thirty- 
seven of these children had bilateral or unilateral sub- 
dural hematomas that resulted in brain damage. 

Gregg and Elmer (12) investigated the question, 
Does cognitive impairment antedate abuse or is it one 
of its effects? They reported that none of the 30 abused 
children they studied had had physical defects that 
might have affected the quality of parental care. 

They also compared these 30 abused children with 83 
children who were thought to have had accidental in- 
juries. Consideration of the behavior of these children 
included subjective assessment of mood, activity level, 
and distractibility. No significant differences were 
found. In fact, Gregg and Elmer suggested that the 
abused children appeared to be easier babies to care 
for. Martin (13) corroborates this finding. 

The available literature suggests that child abuse is 
definitely associated with head trauma and brain 
damage. The literature has also attempted to demon- 
strate that when an abused child is diagnosed as having 
brain damage, the chances are that the neurological 
impairment is a result of, rather than a cause of, the 
physical abuse. 

Trauma and mental retardation 

Documenting the fact that brain damage can cause 
mental retardation is probably unnecessary. Thousands 
of severely and profoundly retarded individuals in in- 
stitutions throughout the United States are sufficient 
testimony to this etiological relationship. 

Martin (13) reported that 93% of the abused children 
in his study who were evaluated as retarded had a 
history of severe head trauma. Another interesting 
finding was that 75% of the abused children he studied 
who exhibited impaired speech and language delay 
were evaluated as having normal intelligence. This 
suggests that head trauma, even when it does not result 
in mental retardation, may contribute to language de- 
lay. Thus, head trauma and brain damage seem fre- 
quently to be apparent causes of both mental retarda- 
tion and less aberrant forms of intellectual dysfunction, 
such as speech disorders. 

Conclusion 

Following this deductive approach, one might now 
conclude that child abuse may well be a very significant 
contributor to mental retardation. However, the ques- 
tion still exists: How many child abuse cases result in 
mental retardation annually? 



20 



U.S. Navy Medicine 



In the absence of research that answers this ques- 
tion, one can only do as Brandwein (4) did, and specu- 
late. 

The NORC study on child abuse, carried out in 1965 
and reported by Gil (8) in 1970, estimated that between 
2.53 and 4.07 million cases of abuse had occurred dur- 
ing the one-year reporting period. An ultraconservative 
speculator will accept only one half of the lower esti- 
mate, or 1.27 million cases of abuse annually. 

In the Kempe study (2), where 749 cases of abuse 
were reported in a nationwide survey, 78 of these 
cases resulted in death. Of the remaining 671, 114 
cases, or 17%, involved permanent brain damage. 
Again being ultraconservative, we might accept half 
this percentage — or 8.5% — as an estimate of the per- 
centage of child abuse cases that result in permanent 
brain damage. Applying this estimate to the 1.27 mil- 
lion annual cases of abuse arrived at above, we can 
hypothesize that 107,950 child abuse cases each year 
result in permanent brain damage. 

Referring now to Martin's study (13), we find that 
more than 60% of the abused children who were diag- 
nosed as having skull fracture, subdural hematoma, or 
neurologic sequelae were evaluated as retarded. Esti- 
mating conservatively again, and applying half that 
percentage rate — or 30% — to our estimate of 107,950 
annual abuse cases resulting in permanent brain dam- 
age, we can hypothesize that 32,385 cases of child 
abuse result in mental retardation annually. This figure 
is probably an underestimate, considering the emo- 
tional and interpersonal neglect and impoverishment 
these children may sustain as well. Each of these fac- 
tors crucially affects not only intellectual development, 
but also social development, which — according to the 
American Association for Mental Deficiency — is equal- 
ly important in evaluating retardation. 

Obviously, one cannot arbitrarily apply figures from 
one set of data to another unrelated set with any valid- 
ity. These calculations do not represent sound scientific 
analysis; nevertheless, in the absence of sound scien- 
tific investigation of this problem, these deductions 
demonstrate that there is good reason to suspect that 
child abuse may be significantly involved in the inci- 
dence of mental retardation. 

The researcher studying the etiology of mental sub- 
normality must attempt to isolate various confounding 
variables and control for them. This has yet to be done. 

It has been pointed out that most of the abused chil- 
dren in these studies were not believed to have been 
retarded prior to abuse (Gregg and Elmer, 12; Martin, 
13). This point helps to counter the argument that chil- 
dren who are abused were probably retarded to begin 
with. 

Many argue that child abuse is a phenomenon pecu- 
liar to the lower class and, therefore, that any retarda- 
tion found among abused children is more likely to be a 
function of cultural-familial retardation than of abuse- 
related causes. This paper has countered this argument 



in two ways. First, it has been pointed out that no class 
has a monopoly on child abuse (Fontana, 5; Gil, 8; 
Steele and Pollock, 10). Second, it has been demon- 
strated that child abuse is often accompanied by head 
trauma and brain damage, which frequently contribute 
to the child's mental subnormality (Apthorp, 11; Gil, 8; 
Kempe et al., 2; Martin, 13). This is not to say that 
cultural-familial factors may not contribute to an 
abused child's mental subnormality, but in many in- 
stances they can hardly be considered the major fac- 
tors. 

One final point should be made. A number of studies 
have shown that in most instances the abusive parent 
was at one time an abused child (Fontana, 5; Schneider, 
Pollock, and Heifer, 14; Steele and Pollock, 10; 
Walters, 15). Fontana stated that in many cases he has 
studied, this parental abuse "goes back for genera- 
tions, and I am afraid it might go forward for many 
more." 

The implication of this consistent factor among abu- 
sive parents is indeed serious. Just as genetic defects 
— a major cause of mental retardation — are passed on 
from generation to generation, so too may be the social 
malady of child abuse. Therefore, in the battle to de- 
crease mental retardation, child abuse as a postnatal 
cause deserves more than cursory investigation by pro- 
fessionals in the field of mental health. 

References 

1. Caffey, cited by Fontana VJ: Somewhere a Child Is Crying. 
New York: Macmillan Publishing Co., 1973. 

2. Kempe CH, Silverman FN, Steele BF, Droegemueller W, 
Silver HK: The battered child syndrome. JAMA 181:17-24, 1962. 

3. Robinson NM, Robinson HB: The Mentally Retarded Child. 
New York: McGraw-Hill, 1976, p 163. 

4. Brandwein H: The battered child: a definite and significant 
factor in mental retardation. Ment Retard 11:50-51, 1973. 

5. Fontana VJ: Somewhere a Child Is Crying. New York: Macmil- 
lan Publishing Co., 1973. 

6. Bakan D: Slaughter of the Innocents. San Francisco: Jossey- 
Bass, Inc., 1971, p 5. 

7. Zalba SR: The abused child: a survey of the problem. Soc Work 
11:3-16, 1966. 

8. Gil DG: Violence Against Children. Cambridge: Harvard Uni- 
versity Press, 1970. 

9. Heifer RE, Kempe CH (eds): The Battered Child. Chicago: The 
University of Chicago Press, 1968. 

10. Steele BF, Pollock CB: A psychiatric study of parents who 
abuse infants and small children, in Heifer RE, Kempe CH (eds): The 
Battered Child. Chicago: The University of Chicago Press, 1968, p 
106. 

11. Apthorp, cited in Brandwein H: The battered child; a definite 
and significant factor in mental retardation. Ment Retard 11:50-51, 
1973. 

12. Gregg GS, Elmer E: Infant injuries: accident or abuse? Pediat- 
ries 44:434-439, 1969. 

13. Martin H: The child and his development, in Kempe CH, 
Heifer RE (eds): Helping the Battered Child and His Family. Phila- 
delphia: J.B. Lippincott Co., 1972. 

14. Schneider C, Pollock C, Heifer RE: Interviewing the parents, 
in Kempe CH, Heifer RE (eds): Helping the Battered Child and His 
Family. Philadelphia: J.B. Lippincott Co., 1972. 

15. Walters DR; Physical and Sexual Abuse of Children: Causes 
and Treatment. Bloomington: Indiana University Press, 1975. 



Volume 69, July 1978 



21 



Professional 



The Role of Preventive Dentistry in the Navy 



Preventive dentistry has no rigid borders: it encom- 
passes all treatment procedures and areas of knowl- 
edge and research that aim to preserve the teeth in 
health and beauty for a lifetime. Preventive dentistry 
focuses on the cause of dental disease; therefore, it is 
hard-nosed therapy. 

Preventive dentistry in the Navy, or in any practice, 
is important not just for the health and appearance of 
those we serve. Dental disease has both social and 
economic impact: social because it is with the mouth 
that we communicate with others (we speak, we sing, 
we pout, frown, or smile); economic because dental 
care is time-consuming and costly. Thus prevention is 
important for the total well-being of the beneficiaries of 
our dental-care system. 

Preventive dentistry has a functional role, too. Em- 
ployee time off the job to receive dental care not only 
lightens the employee's wallet but creates a problem in 
economics for the business manager as well. Within our 
military services, we must also consider the impact of 
dental diseases on combat-readiness. Thus we face 
more immediate and urgent dental health care needs 
than our civilian colleagues. 

In these days of spiraling costs, the role of pre- 
vention has a sound basis. It is with prevention that we 
can attain cost-effective maintenance health care in the 
population. We can never hope to achieve that by treat- 
ing only the demands, or existing needs, of those we 
serve. 

The problem we face is not new. Past studies of re- 
storative treatment for the average Navy enlisted man 
indicate this result: 

5.98 carious teeth on enlistment 
6.70 restorations done in the service 



TABLE I. Dental Profile of the Naval 
Recruit at Great Lakes, 1976 



2.26 carious teeth on separation 

Not very good arithmetic, is it? 

If we invest our talents in the restoration of carious 
teeth we will, as we have learned in our universities, 
place those restorations to last a lifetime. But if we do 
not also help our patients stop the disease of dental 



Decayed Teeth 
Missing Teeth 
Restored Teeth 
DMFT 


5.4 

0.6 

6.7 

10.7 


Navy Periodontal Disease Index 
Navy Plaque Index 


6/19 
17/85 


Calculus Surface Index (modified) 


9.2 



caries, those restorations are love's labor lost. 

Because of the lack of meaningful dental standards 
for entry into military service, the Navy incurs a huge 
dental treatment liability with each new group of re- 
cruits. 

The dental profile of incoming recruits at Great Lakes 
today is shown in Table I. Projecting those indices into 
treatment needs shows a great deal of dentistry to be 
done (Table II). If all 111,557 naval recruits received in 
1977 had had these treatment requirements, we esti- 
mate that 30 percent of our dental officer resources 
would have been consumed in their care. Our additional 
responsibility for Marine Corps recruits would have left 
us with less than half our resources to care for all the 
operating forces of the Navy. 

A recent survey of dental records revealed that 15 
percent of Navy and Marine Corps personnel have ad- 
vanced dental disease with the potential to compromise 
personnel effectiveness. Translating the proportions of 
destructive dental disease described above into military 
relevance, the high levels of caries and periodontal 
disease detract from the combat readiness of Navy and 
Marine Corps personnel. A survey of "in country" 
Navy and Marine Corps personnel in Vietnam, 1969- 
1970, demonstrated that as many as 18.8 per thousand 
had to leave their combat assignments to receive emer- 
gency dental care, mostly related to dental caries. In 



22 



U.S. Navy Medicine 



CAPT M.R. Wirthlin, Jr., DC, USN 



addition, acute dental emergencies repeatedly occur 
throughout the fleet and have the potential for inter- 
rupting fleet operations and aborting tactical missions. 
Oral health problems of submarine crews are known to 
have disrupted schedules and reduced operating effi- 
ciency. 

Moreover, naval personnel may be required to 
operate for extended periods in hostile and isolated 
environments without access to dental care, e.g., as 
prisoners of war. The following comments from two 
repatriated POWs illustrate the point: 

. . . [T]he person who is sitting in a prisoner of war camp — even 
though at the present time he does not feel toothache — he is aware 
that in the future it is going to return again, again, and again. He also 
knows there is no relief in sight. . . 

There is no other problem that can guarantee so much pain, so often, 
as dental problems. I suggest, then, that the dental problem is one of 
the more severe problems that the prisoners of war experience. 

The role of preventive dentistry in the Navy is to help 
manage dental health care needs. In handling the year- 
ly workload of recruit dental needs, we must rely on 
prevention to stop the runaway incidence of disease in 
the total force. 

It is unlikely that we will get more dental officers and 
more dental technicians. We must rely on preventive 
dentistry. 

The solution 

The Navy's preventive dentistry program is founded 
on (1) educational procedures that will develop proper 
oral health habits and knowledge, and (2) techniques 
that will prevent the initiation of oral disease. 

All dental activities have a preventive dentistry pro- 



Dr. Wirthlin is commanding officer of the Naval Dental Research 
Institute, Naval Base, Bldg. 1-H, Great Lakes, IL 60088. 

This paper was presented, in part, to the Dental Section, 84th An- 
nual Meeting of the Association of Military Surgeons of the United 
States, 30 Nov 1977. 



gram that includes, as a minimum, the following ele- 
ments: 

• Topical fluoride application. All Navy and Marine 
Corps personnel shall receive a topical fluoride treat- 
ment annually and prior to deployment or transfer to 
activities or areas where dental support is other than 
maximum, 

• Navy periodontal screening examination. This 
examination is to be conducted annually for all active 
duty personnel. 

• Plaque control program. Plaque control instruction 
shall be given through individual or small group ses- 
sions. These sessions shall include, as a minimum: (1) 
education regarding the relationship of plaque to caries 
and periodontal disease; (2) demonstration of inter- 
proximal plaque removal techniques; (3) demonstration 
of sulcular methods of tooth cleansing with a tooth- 
brush; (4) instruction in the use of plaque disclosing 
media. 

• Children's program. Each eligible child shall 
receive an annual oral health examination, a prophy- 
laxis, a topical application of aqueous fluoride solution, 
a lecture and demonstration on plaque control, dental 
health education materials, and a preventive dentistry 
kit. 

Dental activities located ashore shall determine the 
source of the base water supply and its fluoride content. 
If the water supply is fluoride deficient or contains 
higher than optimum fluoride levels, efforts shall be 
directed toward proper adjustment where feasible. 

• Month guards. All dental activities with limited or 
full prosthetic capabilities shall offer to provide protec- 
tive mouthpieces for all active-duty personnel engaged 
in sports involving body contact. 

• Preventive dentistry officer. A dental officer shall 
be appointed as the preventive dentistry officer at each 
dental activity. 

In support of the above program, the role of the den- 
tal officer has three main points of emphasis. At a com- 
mand, staff, or management level, he must show true 
conviction, ideals, and enthusiasm in support of pre- 



Volume 69, July 1978 



23 



ventive dentistry programs. He should encourage all 
dental officers to participate in and reinforce the 
preventive dentistry program, and he should show his 
fellow commanders in the line what the payoff is. 
Dental health is the responsibility of Command. Unless 
the ship or troop commander is convinced of the bene- 
fits of good dental health for the status of his forces, the 
preventive dentistry program cannot succeed. 

The dental officer has a role in the early recognition 
and treatment of oral diseases. He must learn to do the 
Navy periodontal screening examinations, for they have 
a real purpose. He must see that the stannous fluoride, 
plaque control, and oral prophylaxis treatments are 
done well. Since many of these preventive procedures 
are delegated to auxiliaries, the dental officer must 
exercise leadership and not shirk his role as a super- 
visor. He must see to it that preventive procedures are 
done thoroughly, or they will not work. 

The dental officer must also learn new skills. It is, of 
course, important to carve amalgam restorations well, 
so that there are no gingival overhangs. It is important, 
too, to educate the patient concerning the relationship 
of plaque to dental caries and periodontal diseases. It is 
necessary to thoroughly scale off deposits from the 
teeth to make them smooth and easier for the patient to 
clean, and to help the patient learn skills with brush, 
floss, toothpick, and disclosant. 

But the dental officer must also understand that 
caries and periodontal diseases are social diseases; 
they are related to social class and educational status. 
These factors, more than any dental treatment or chem- 
ical mouthwash developed by research, will cause 
changes in oral hygiene. The dental officer must there- 
fore learn to use social sciences, become a behaviorist, 
and learn to prevent plaque control in accordance with 
the felt needs of the patients and their social aspira- 
tions. 

Finally, the individual sailor and marine have a role 
in preventive dentistry in the Navy. They must make a 
personal commitment to effective daily cleansing of 
their teeth, to a sensible diet with reduction of sugar, 
and to a regular recall examination schedule. 

Dental enemy, first class 

The dental enemy, first class, is the bacterial plaque 
deposit on the teeth. Plaque may sometimes be so thick 
that it is obvious to the unaided eye, but its detection is 
assisted by disclosing agents. Although all plaques may 
look the same to the dental officer, different sites pro- 
vide ecological niches that allow certain microorga- 
nisms to become established. 

Streptococcus mutans has been strongly associated 
with dental caries in man and laboratory animals and is 



TABLE II. Initial Projected Treatment per 1,000 
Naval Recruits at Great Lakes 



Operative and Crown and Bridge 




Amalgam {one surface) 


3,161 


Amalgam (two or more surfaces) 


2,752 


Root canal filling 


83 


Bridge 


4 


Crown 


28 


Prosthodontics 




Full denture 





Partial denture 


31 


Oral Surgery 




Root, residual removal 


118 


Tooth removal 


374 


Periodontics and Oral Hygiene 




Gingivectomy 


16 


Prophylaxis 


996 


Scaling (periodontal) 


728 


Caries prevention treatments 


2,000 


Plaque control instruction 


4,744 


Examination 




Examinations and consults 


1,815 


X-rays 


4,224 


Miscellaneous 


7,611 


Total 


28,685 



considered the main cause of cavities. This bacterium 
produces a sticky slime about itself, composed of 
glucans of differing solubility. These glucans help it 
adhere to the tooth and may help localize acids on the 
tooth surface. Glucans and acids are the result of sugar 
metabolism, and mutans prefers sucrose, or table 
sugar, to other sugars. 

Streptococcus mutans prefers to colonize on the 
teeth. We do not find it in newborns, or in children until 
there are posterior interdental tooth contacts. In naval 
recruits, it is most abundant in the posterior proximal 
spaces. It is probably transmitted from parents to off- 
spring. 

Periodontal diseases may also be infectious diseases, 
caused by bacteria harbored within or about bacterial 
plaques. Studies have shown development of gingivitis 
in association with plaque at the gingival margin, and 
its resolution with plaque control or removal. 

Periodontal diseases can be induced in animals by 
actinomyces and some gram-negative anaerobes. Some 
streptococci also cause periodontal diseases in animals, 
but do not seem strongly associated with human gingi- 
vitis. 

As plaque extends into the gingival sulcus, and 
thence into the crevice, there develops a complex of 



24 



U.S. Navy Medicine 



attached plaque and, on its soft-tissue face, a mixture 
of spirochetes and gram-negative rod and filamentous 
forms, some of which are flagellated. In so-called 
periodontosis, almost all microorganisms are of the 
latter, unattached types. 

Research role in preventive dentistry 

Preventive dentistry measures developed by the 
National Institute of Dental Research are primarily con- 
cerned with preschool and elementary school age popu- 
lation groups. In spite of exciting results reported in the 
past few years, there is no clear indication of a dramatic 
breakthrough that may soon result in new and signifi- 
cant agents for prevention of destructive dental dis- 
eases. Meanwhile, the Navy Dental Corps is faced with 
overwhelming proportions of dental caries, especially 
in the 17-24 age group, and with a periodontal disease 
rate of almost 100 percent in naval personnel. 

In order to fulfill its mission of providing dental care 
for all active-duty naval personnel, the Navy Dental 
Corps must conduct research to develop more efficient 
techniques for control and prevention of destructive 
dental diseases and injuries. These studies can be con- 
ducted by no other federal or private agency. 

Cost-effective, innovative methods must be devel- 
oped to bring our treatment liabilities into congruence 
with our ability to provide those treatments. Preventive 
and treatment measures must be demonstrated as safe 
and effective for mass application in the naval service. 
Identifying and treating servicemen with a high risk of 
incapacitating dental problems is a continuing need if 
we are to maintain a sound defense posture. 

Our goal in preventive dentistry research is to ensure 
that Navy and Marine Corps personnel enjoy a lifetime 
of health and attractive appearance of the oral struc- 
tures. These health benefits can be realized from early 
diagnosis, which singles out incipient lesions at a re- 
versible stage, and from available, highly effective, and 
personally acceptable preventive measures. 

Our strategies for prevention are (1) prevention of 
tissue destruction, and (2) early diagnosis and treat- 
ment of incipient lesions. 

The first strategy has two components: prevention of 
tooth destruction and prevention of oral bone destruc- 
tion. Each of these components can be further divided 
into problems of controlling or eliminating the patho- 
genic organism, improving host resistance, and 
altering microbial substrates. 

At the Naval Dental Research Institute, current work 
units for control of pathogenic microorganisms involve 
the giucans, which make the plaque sticky and 
insoluble, and the use of fluorides or other antibacterial 
agents. 



Until such time as we have evaluated these new pre- 
ventive measures for effectiveness, and have shown in 
community demonstration projects that they are worthy 
of implementation as public health measures, the 
dental officer of today must rely on his three-agent 
stannous fluoride treatments and plaque-control in- 
struction to manage the incidence of new diseases. 

We have evaluated the current Navy plaque control 
program by following recruits over a six-month period, 
through completion of their service school instruction at 
Great Lakes. As a result of group plaque control in- 
structions, using the Navy dental health series films 
(MN 11214 A-E) 'Tour Teeth Are in Your Hands," we 
have found initial short-term reductions of plaque. The 
net result was a significant reduction of the Navy Pla- 
que Index, at the end of six months, by 3 percent. There 
was a parallel reduction of the Navy Periodontal Dis- 
ease Index by 4 percent. 

Evaluation on a dose-response basis showed trends 
of increasingly favorable response with an increasing 
number of preventive dentistry treatments. There were 
trends toward reduction of caries attack rate, too, but 
these were not statistically significant. Individual in- 
struction by the dental officer, as a supplement to 
group instruction, was found to further improve the 
effect. 

The posterior proximal surfaces of the teeth were 
found to accumulate the greatest amount of plaque, and 
those sites had the highest caries attack rate. Our work 
for this year is to evaluate a new plaque control pro- 
gram which uses educational psychology and empha- 
sizes interdental cleaning, and in which all clinical per- 
sonnel participate in individual reinforcement of plaque 
control with their patients. 



Summary 

Preventive dentistry is vital to the overall manage- 
ment of dental health care delivery in the naval service. 
Without a strong preventive dentistry program, we can- 
not hope to fulfill our mission of prevention and treat- 
ment of diseases and injuries that may interfere with 
the performance of naval duties. 

Each member of the naval service has a role to play, 
whether that individual is a commander, a dental offi- 
cer, a dental technician, a sailor, or a Marine. 

Dental research has a role to play, too. We have a 
vigorous program of work units before us, with the goal 
that Navy and Marine Corps personnel will enjoy a life- 
time of health and attractive appearance of the oral 
structures. We hope to achieve this by providing dental 
officers with efficacious, cost-effective, personally ac- 
ceptable, and proven preventive health measures to use 
in their daily practice. 



Volume 69, July 1978 



25 



Professional 



Outpatient Medical Records Audit: A Dialogue 



Editor: 

Dr. Leslie C. Ellwood's article "Outpatient Medical 
Records Audit," which appeared in the January issue 
of U.S. Navy Medicine, leaves a great deal to be de- 
sired as an example of medical audit. While his intent 
may have been worthwhile, his resultant misinterpreta- 
tion and misuse of generated data is at best misleading. 

First, to refer to two articles (2,3) relating specifically 
to one professional discipline and subsequently make a 
statement that "Audit of outpatient medical records is 
generally reviewed pessimistically ..." is somewhat 
incredible in itself. Furthermore, review of the refer- 
enced articles does not relate a pessimistic view of out- 
patient audit to this reader. Pessimistic views en- 
countered in medical audit are usually a result of poor 
design, improper implementation, and inadequate edu- 
cation (4-9). 

Second, "lack of accepted criteria of care" and "in- 
adequate recording of care delivered by physicians" 
are not valid problems associated with implementation 
of medical audit. Criteria sets, such as the American 
Medical Association's model screening criteria (10), are 
readily available for use or modification by the medical 
staff. Discovery of inadequate recording of treatment 
provided is one of the primary functions of medical 
audit, and as such certainly presents no problem in 
initiating medical audit. 

Third, although Dr. Ellwood was able to document 
the quality of medical care provided, his interpretation 
of that documentation does not seem justified by the 
data he himself presents. An unexplained absence of 
13.5% (34/244) of identified records indicates a 
problem area itself and suggests a need for further in- 
vestigation. A variation analysis of the data presented 
differs significantly from the "error rate of 3.17%" ex- 
pressed in the article. The term "error rate" itself is 
neither desired nor standard in discussing variances 
from an expressed criterion standard, but should be re- 
placed by the term "variation." Furthermore, varia- 
tions from criterion standards are reported individually 
for each element, not lumped together and an average 
rate expressed. 

An expanded version of the "Outpatient Process 
Audit for Acute Otitis Media" is presented in Figure 1. 



Element 1 indicates that the reported practice should 
be 98% (200/204) to reflect the statement that there 
were "four errors noted in which the diagnosis of in- 
fected eardrum failed to describe both middle ear fluid 
and inflammation." 

Element 3 indicates that the reported practice should 
be 94.7% (193/204), indicating a variation of 5.3% to 
reflect the statement that "In 11 entries we could not 
determine the milligram dosage of antibiotic pre- 
scribed ..." 

Element 4 indicates that the reported practice should 
be 97.6% (199/204), indicating a variation of 2.4% to 
reflect the statement that "in 5 chart entries the dosage 
schedule was not recorded." 

Element 5 indicates that the reported practice should 
be 73.6% (150/204), indicating a variation of 26.4% to 
reflect the statement that "54 chart entries failed to 
give this information" (the duration of therapy). 

Element 8 indicates that the reported practice should 
be 81.9% (167/204), indicating a variation of 18.1 % to 
reflect the statements that "The number of appoint- 
ments lost because patients failed to appear was 24," 
and "failure to record patient compliance with pre- 
scribed antibiotic regimen when persistent otitis media 
was noted in followup exam . . . occurred in 13 of 49 
chart entries ..." 

Complication rate analysis reveals similar findings. 
Element 1 indicates that the complication rate should 
be 39.2% (80/204) to reflect the statement that "serous 
otitis media following acute otitis media was noted in 80 
charts ..." 

Element 2 indicates that the complication rate should 
be 21.5% (44/204) to reflect the statement that "Per- 
sistent fluid and inflammation after antibiotic therapy 
were recorded in 44 charts ..." Furthermore, critical 
management was not met in 26.5 % (13/49), as noted by 
the statement that ' 'failure to record patient compliance 
with prescribed antibiotic regimen when persistent 
otitis media was noted in followup exam . . . occurred in 
13 of 49 chart entries ..." 

These figures seem to imply more significant and 
realistic problem areas than does "an error rate of 
3.17%." 

The fourth main objection to the article is the manner 



26 



U.S. Navy Medicine 



FIGURE 1 . Outpatient Process Audit tor Acute Otitis Media 






Reported 




Elements 


Standard 


Practice 


Exceptions 


Justification for Diagnosis: 








1. Examination must reveal both: 


100% 


98% 




a. Evidence of substance other than air behind 








tympanic membrane 








b. Evidence of inflammation 








Therapy: 








2. Requires antibiotics 


100% 






3. Prescribed antibiotic minimum recommended 
dosage 


100% 


94.7% 










4. Dosage schedule of antibiotic at least t.i.d. 


100% 


97.6% 




5. Medication prescribed for at least 7 days 


100% 


73.6% 




6. Antibiotic spectrum H. influenzae when child 






Therapy is for persistence of otitis, 


is older than 4 years 






and initial therapy covers H. in- 
fluenzae 


Recurrence noted: 








7. More than 2 acute otitis in preceding 3 months 








noted by physician 








Followup: 








8. Final followup exam for acute otitis media 


100% 


81.9% 


Final chart entry meets critical 


episode reveals normal ear by otoscopy 






management for complication, or 
ENT referral completed 


Complications: 






Critical Management: 


1 . Serous otitis media 


0% 


39.2% 


1. Decongestant, followup sched- 
uled 


2. Persistence of infection 


0% 


21.5% 


2. Antibiotics (Note indicates 
probable compliance with initial 
therapy; followup scheduled) 


3. Perforation 


0% 




3. Followup scheduled 


4. Allergic reaction to antibiotic 


0% 




4. Noted: antibiotic discontinued 


5. Severe diarrhea 


0% 




5. Noted for future antibiotic choice 



in which the audit itself was performed. Twenty-nine 
valuable physician-auditor hours is an unbelievable 
waste of physician time. The initial screening of all pa- 
tients' charts should have been performed by medical 
records personnel, utilizing the audit criteria, and only 
those records not meeting the criteria should be sub- 
mitted for formal physician peer review. 

While it is fervently hoped that all disciplines in- 
volved in medical care will become actively involved in 
medical care evaluation studies, haphazard perform- 
ance and reporting of these studies tend only to detract 
from the overall value and usefulness in assuring qual- 
ity medical care. 



ENS Craig A. Jimerfield, MSC, USN 

Medical Audit/Utilization Review 

Patient Affairs Service 

Naval Regional Medical Center 

Oakland, CA 94627 



References: 

1. Ellwood LC: Outpatient medical records audit. U.S. Nav Med 
69(l):26-28, 1978. 

2. Mead W: Quality assurance for health supervision of the am- 
bulatory child. J Fam Pract 3(6):587-591, 1976. 

3. Osborne C, Thompson H: Criteria for evaluation of ambulatory 
child health care by chart audit: development and testing of a meth- 
odology. Pediatrics 56(suppl 4):625-629, 1975. 

4. Jacobs CM, Christoffel TH, Dixon N: Measuring the Quality of 
Patient Care- The Rationale for Outcome Audit. Cambridge: 
Ballinger Publishing Co., 1976. 

5. Davidson SV: PSRO Utilization and Audit in Patient Care. 
Saint Louis: The C.V. Mosby Co., 1976. 

6. Ertel PY, Aldridge MG: Medical Peer Review: Theory and 
Practice. Saint Louis: The C.V. Mosby Co., 1977. 

7. Zentmyer RK: Health care evaluation: it really works. U.S. 
Nav Med 66(2)9-15, 1975. 

8. Porterfield JD: Why audit. Qual Rev Bui 1(1):2, 1974. 

9. Williamson JW: Evaluating quality of patient care, a strategy 
relating outcome and process assessment. JAMA 218(4):564-569, 
1971. 

10. Mode! Screening Criteria to Assist Professional Standards Re- 
view Organizations. Chicago: AMA, May 1975. 



Volume 69, July 1978 



27 



Editor: 

ENS Jiraerfield's comments and clarifications con- 
cerning the article "Outpatient Medical Records 
Audit" (/) are most welcome, as they contribute to a 
better understanding of these audits. 

Outpatient medical record audit, while theoretically 
feasible, in practice is difficult to perform in a manner 
which yields relevant data as to the quality of care the 
patient has actually received (2,3,4). 

To quote from the originally referenced articles, Dr. 
Mead, writing in the Journal of Family Practice, noted 
that "Since criteria were found recorded less than 50 
percent of the time by both pediatricians and other 
physicians, it is obvious that chart audit is unsatisfac- 
tory at this time/' In his conclusions, he states that "in 
view of the present chart systems and recording pat- 
terns, it is apparent that meaningful peer review of 
health supervision by chart audit is not possible at this 
time." (2) 

Pediatrics Supplement 4, in 1975, indeed did not 
have any significant problems in devising model audits, 
but when attempting to perform the audit had several 
problems. Osborne and Thompson wrote: "In contrast 
to the acceptance of audits in hospitals, few physicians 
have been willing to review ambulatory care or office 
practice because it seems virtually impossible to docu- 
ment what actually occurs." Potential problems in 
chart audit were described as including "lack of stand- 
ardization of recorded information . . . and information 
is frequently incomplete and inadequate." (3) 

I personally find these statements pessimistic, and 
my daily observation of military medical records on the 
30 to 35 patients I see each day would indicate no re- 
markable improvement in medical recording since 
these articles were written. 

Medical record audits which will document the con- 
sistent major problems of inadequate physician record- 
ing of outpatient care delivery, patient possession of 
medical records, and treatment failures due to the mul- 
tiplicity of factors found in outpatient practice unrelated 
to physician performance, can provide a measure of the 
variances of these elements. But these variations sig- 
nificantly impede our ability to measure actual physi- 
cian care variations from acceptable management. A 
recent report about a military facility's outpatient audit 
further documented these problems (4). 

ENS Jimerfield's analyses of the variances found in 
our audit of otitis media in pediatric patients are very 
correct, technically, and highlight the elements which 
make measurement of individual physician variation, as 
contrasted with institutional variation, difficult. The 
absence of 13.5% of identified records is a problem 
area, but it is a result of patients' possession of their 
health records in a medical region where they must ob- 
tain care from branch clinics and the regional medical 
center, and of the transience of our patient population. 



1 agree that ENS Jimerfield's analyses of elements 1 
through 7 are correct. 

Inclusion of missed appointments in element 8 is 
technically correct as an institutional variation, but is 
not physician variation. Failure to record patient com- 
pliance is a variance of complication management. Ex- 
clusion of these variations from analysis of element 8 
(followup), which is the closest estimate we have of out- 
come, yields a very low variation for individual physi- 
cian record-keeping in our clinic during this audit. 

In this particular diagnosis, the significant complica- 
tions of persistent infection (21.5%) or serous otitis 
media (39.2%) are not the result of inappropriate physi- 
cian practice but of the nature of the disease (J). The 
purpose of analysis of complications is to determine if 
the physician completed the critical management, and 
in this audit the physicians did. 

I applaud ENS Jimerfield's fourth objection about the 
necessity for the physician to perform the audit. Unfor- 
tunately, the ADM Joel T. Boone Clinic does not have 
medical records personnel trained in medical audit, 
and, in fact, personnel hiring ceilings do not provide 
sufficient medical records clerks to perform all the 
other essential chores in a timely manner. If the audit 
were not entirely performed by a physician reviewer, 
there would be no audit. 

If outpatient medical records audit for quality of care 
review is to be performed at only the health facilities 
where persons of ENS Jimerfield's technical caliber are 
assigned, then a very large proportion of Navy outpa- 
tient health records and physicians will never be 
audited. 

Adaptation of this system of quality review to local 
skills and needs does not detract from its value or use- 
fulness in assuring quality medical care. Our audits do 
raise the quality of care delivered and of medical 
records entries, and thus fulfill the purpose for which 
all audits are designed. 

CDR Leslie C. Ellwood, MC. USN 

Pediatrics 

ADM Joel T. Boone Clinics 

Naval Amphibious Base Little Creek 

Norfolk, VA 23520 



References: 

1. Ellwood L: Outpatient medical records audit. U.S. Nav Med 
6 Q U):26-28, 1978. 

2. Mead W: Quality assurance for health supervision of the am- 
bulatory child. J Fam Pract 3(6):587-591, 1976. 

3. Osborne C, Thompson H: Criteria for evaluation of ambulatory 
health care by chart audit: development and testing of a methodol- 
ogy. Pediatrics 56(suppl 4):625-629, 1975. 

4. Burney R, Newman J: Experience with retrospective medical 
audit in ambulatory care. Milit Med 143(1 ):29-31, 1978. 

5. Bluestone C, Shurin P: Middle ear disease in children: patho- 
genesis, diagnosis, and management. Pediatr Clin North Am 21(2): 
379-400. 1974. 



28 



U.S. Navy Medicine 



BUMED SITREP 



SG's TESTIMONY . . . VADM Willard P. Arentzen, 
appearing before the Defense Subcommittee of the 
House Committee on Appropriations 8 May 1978, out- 
lined a number of initiatives to ease the Navy Medical 
Department's current physician shortage (a problem 
shared by all three military medical services) and to up- 
grade Navy medical facilities. 

Some of the reasons most frequently cited for the 
shortage of military doctors, VADM Arentzen noted, 
are the financial rewards of private practice; insuffi- 
cient ancillary support personnel and "cumulative 
degradation of facilities and equipment," resulting 
from fiscal restraints; and inability to provide adequate 
support for continuing medical education. 

'"The current situation is bad," he said. "However, I 
do not believe it is hopeless. The physician shortage 
may be turned around relatively soon if we obtain the 
support required." 

VADM Arentzen noted that DOD has developed a 
legislative proposal to stabilize special pay for physi- 
cians, thus helping to reduce financial uncertainty. In 
addition, he said, the Navy has recommended in- 
creased funding for FY79 for additional ancillary sup- 
port personnel, maintenance and repair of medical 
facilities, and support of continuing education. 

Meanwhile, VADM Arentzen said, "We are not just 
sitting around wringing our hands." The Navy Medical 
Department has "significantly reduced the number of 
physicians in administrative positions," he reported. In 
addition, BUMED proposes to convert a small number 
of psychiatrist positions to clinical psychologist posi- 
tions, some anesthesiologist positions to nurse anes- 
thetist positions, and some general medical officer 
positions to clinical nurse/primary-care nurse posi- 
tions. In certain areas such as radiology, where there is 
a critical shortage of physician specialists for whom no 
other health personnel can reasonably be substituted, 
"We will be attempting to obtain the service by con- 
tract," he said. 

"The health services provided by the Navy Medical 
Department, in terms of quality, are excellent," VADM 
Arentzen said. "We provide the best quality of care 
available. 

"The availability of care is usually what is ques- 
tioned," he added. 



ASBESTOS ALERT ... The Navy, in cooperation with 
the U.S. Department of Health, Education and Wel- 
fare, is attempting to notify Navy people — military and 



civilian — who may have been exposed to airborne 
asbestos that such exposure presents a health risk. 

In recent years, it has become known that inhalation 
of airborne asbestos fibers can lead to serious health 
problems. Dangerous levels of invisible asbestos fibers 
can be created whenever asbestos is cut, milled, or 
processed, unless strict safety precautions are ob- 
served. 

According to recent BUMED guidance, current Navy 
Department civilian employees, their relatives, or their 
designated representatives who wish to file compensa- 
tion claims as a result of asbestos exposure should 
contact the Navy Office of Civilian Personnel (OCP). 
Former civilian employees who wish to file should con- 
tact the U.S. Department of Labor, Office of Workers' 
Compensation Programs, Federal Employees' Com- 
pensation Section. 

Claims of active-duty personnel will be processed 
through the Navy disability evaluation system. Former 
or retired military personnel should file with the Veter- 
ans Administration. 

Present and former contractor employees should file 
with the U.S. Department of Labor, Office of Workers' 
Compensation Programs, Longshore and Harbor 
Workers' Compensation Section, or the state Work- 
men's Compensation authorities, as appropriate. 



AUDIT TIPS . . . Recently completed audits uncovered 
the following discrepancies: 

• Command was recording travel advances as ex- 
penses in its financial records and was allowing trav- 
elers to file travel claims as late as six months after 
completing their trips. NAVAUDSVC recommends that 
the command record travel advances as monetary ad- 
vances and require that travel claims be filed within 15 
days after completion of trip (NAVCOMPT Manual, 
par. 032106-2; NAVSO P-3006-1). 

• Record outpatient treatment to foreign students in 
such a manner as to facilitate reporting to BUMED for 
billings to foreign governments. (BUMED letter BU- 
MED :462:JLP:arh 6320 of 22 Dec 1977 promulgated an 
advance change to the Financial Management Hand- 
book [NAVMED P-5020] for all BUMED-commanded 
activities. This advance change provided detailed in- 
structions on how to report outpatient visits for FMS 
students and their dependents to the Bureau for cen- 
tralized billing. Additionally, Change 21 to NAVMED 
P-5020, incorporating the detailed instructions, will be 
distributed in the near future.) 



Volume 69, July 1978 



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